Treatment Of Kidney Failure Research Articles

A choice experiment of older patients’ preferences for kidney failure treatments

Most older people with kidney failure choose between treatment with dialysis or conservative kidney management. The preferences underlying these decisions are poorly understood. Here, we performed a choice experiment, informed by qualitative research, to examine preferences for the characteristics of dialysis and conservative management among over-65- year-olds with eGFR of 20mls or under/min/1.73m2. Mixed logit and latent class analyses quantified the trade-offs between frequency and location of treatments, survival, and capability (the ability to do important activities), accounting for participants’ characteristics. Overall, 327 United Kingdom participants across 23 centers (median age 77 years, eGFR 14mls/min/1.73m 2) needed 8%-59% absolute survival benefit two years after starting treatment to accept dialysis, with preferences for less frequent treatment and treatment at home. Significantly higher preferences for survival were seen amongst partnered participants (effect size 0.04, 95% confidence interval 0.02-0.06) and if better levels of capability were depicted (effect size 0.02, 0.01-0.03). Three latent classes were identified with divergent preferences for survival, capability, and location of care. Stated preferences indicated participants favored higher survival probabilities, but only if their capability was preserved and the location and frequency of care were acceptable. Subgroups may prioritize survival, hospital avoidance, or in-center care. Clinicians supporting people making kidney failure treatment decisions must explore their goals and values. Thus, investment in services that prioritize capability and ensure treatment is delivered at a frequency acceptable to people in their preferred location would enable provision of preference sensitive care.

Longitudinal Trajectories of Estimated Glomerular Filtration Rate in a European Population of Living Kidney Donors.

A living donor (LD) kidney transplant is the best treatment for kidney failure, but LDs safety is paramount. We sought to evaluate our LDs cohort's longitudinal changes in estimated glomerular filtration rate (eGFR). We retrospectively studied 320 LDs submitted to nephrectomy between 1998 and 2020. The primary outcome was the eGFR change until 15years (y) post-donation. Subgroup analysis considered distinct donor characteristics and kidney function reduction rate (%KFRR) post-donation [-(eGFR6months(M)-eGFRpre-donation)/eGFRpre-donation*100]. Donors had a mean age of 47.3 ± 10.5years, 71% female. Overall, LDs presented an average eGFR change 6M onward of +0.35mL/min/1.73m2/year. The period with the highest increase was 6M-2Y, with a mean eGFR change of +0.85L/min/1.73m2/year. Recovery plateaued at 10years. Normal weight donors presented significantly better recovery of eGFR +0.59mL/min/1.73m2/year, compared to obese donors -0.18L/min/1.73m2/year (p = 0.020). Noteworthy, these results only hold for the first 5years. The subgroup with a lower KFRR (<26.2%) had a significantly higher decrease in eGFR overall of -0.21mL/min/1.73m2/year compared to the groups with higher KFRR (p < 0.001). These differences only hold for 6M-2Y. Moreover, an eGFR<50mL/min/1.73m2 was a rare event, with ≤5% prevalence in the 2-15Y span, correlating with eGFR pre-donation. Our data show that eGFR recovery is significant and may last until 10years post-donation. However, some subgroups presented more ominous kidney function trajectories.

#2465 How do renal clinicians present treatment options to older patients with advanced kidney disease and what difference does it make?

Abstract Background and Aims For older people with kidney failure, especially those with comorbidities or poor performance status, the survival benefits of dialysis are uncertain and its quality of life impact greatest. Conservative kidney management (CKM) can be a beneficial alternative. However, there is significant variation in treatment rates among older patients with kidney failure; the CKMAPPS study [1] found rates of older people receiving dialysis ranged from 5-95% across UK renal units. How clinicians communicate about treatment options influences patients’ decision-making, but this has been under-researched. The OSCAR study (Optimising Staff-Patient Communication in Advanced Renal disease) aimed to describe how kidney failure treatment options are presented by renal clinicians to older people (age 65+) with advanced chronic kidney disease (eGFR ≤20 mls/min/1.73 m2 within the last 6 months) and the implications of this for patient engagement with the decision. Method Outpatient consultations between doctors/nurses and eligible patients were recorded at 4 UK renal units with varying rates of CKM. Recorded consultations were screened to identify cases where clinicians presented treatment options for advanced kidney disease. Consultations where clinicians presented both dialysis and CKM were transcribed and analysed in detail using Conversation Analysis, focused on how dialysis and CKM were framed. Post-consultation, patients completed the Shared Decision-Making Questionnaire (SDM-Q-9). Comparisons were made between groups according to how treatment options were presented, using a non-parametric Median Test. Results A total of 110 outpatient consultations were recorded (104 audiovisual, 6 audio). Recordings included 38 doctors and nurses and 94 patients; mean patient age 77 (65-97), 33 female/61 male, mean eGFR 15 (range 4-23). Sequences where clinicians presented both dialysis and CKM as treatment options were analysed (n = 21). Two approaches to presenting CKM were identified: 1) CKM as a main option (n = 6; see Fig. 1), 2) CKM as a subordinate option (n = 15; see Fig. 2). The mean consultation length was the same in both groups (23 mins). Recurrent features of the first approach included: framing CKM as having potential personal benefits to the patient; explicitly labelling it as a treatment option; not framing it as an option preferred by or relevant to only a minority of patients. In contrast, when CKM was presented as a subordinate option, recurrent features included: framing CKM as not having benefit to the patient; not explicitly labelling CKM as a treatment option; appending CKM to the main decision-making sequence; framing CKM as an option only chosen by a minority of patients. Presenting CKM as a main option alongside dialysis was a less common approach (n = 6 vs. n = 15), but associated with more interactional opportunities for patients to ask questions about CKM, assert their perspective, and assess CKM as a relevant option, as well as significantly higher patient ratings of shared decision-making (total SDM-Q-9 score, p = 0.041). Conclusion This is the first fine-grained analysis of the relationship between the conversational practices used by clinicians and their impact on patient engagement with treatment options and ratings of shared decision-making. Despite evidence that dialysis does not reliably extend older patients’ lives at acceptable costs to quality of life, we found that clinicians tend to present dialysis as the default treatment and CKM as subordinate, if at all. Our findings demonstrate that presenting treatment options is not enough; how clinicians present options has important implications for patient engagement in shared decision-making. To provide patients with the opportunity to evaluate CKM as a valid option requires clinicians to clearly detail the advantages and disadvantages of both treatments. Study findings will form the basis of a new communication training intervention for clinicians.

#2576 Effect of dialysis versus conservative care on all-cause mortality in older patients with advanced CKD: nationwide Swedish cohort study

Abstract Background and Aims Conservative care is emerging as an alternative to dialysis in older patients with advanced chronic kidney disease (CKD). However, high-quality evidence comparing the effect of dialysis versus conservative care on patient survival is lacking. Previous observational studies suffered from avoidable biases, such as immortal time bias and lead time bias, and adjusted for limited confounders. This study aimed to assess the effects of dialysis versus conservative care on mortality in older patients with advanced CKD. Method The target trial emulation framework was used to design and analyze this observational study. We conducted a nationwide observational cohort study using data from the Swedish Renal Registry between 2007-2021. We included all nephrologist-referred patients with eGFR &amp;lt; 20 ml/min/1.73 m2 who had a registered decision for dialysis or conservative care. Eligible patients were required to be ≥ 65 years with a Davies Comorbidity Score ≥ 2 or ≥ 80 years. The primary endpoint was 5-year all-cause mortality. Inverse probability of treatment weighting was used to adjust for 50 baseline confounders, including demographics, comorbidities, medication use, blood pressure, laboratory measurements, hospitalizations, and calendar year. Patients in the non-overlapping region of the propensity score distribution were excluded since they had an absolute indication for dialysis or conservative care. Cox proportional hazards regression was used to estimate intention-to-treat hazard ratios (HRs) with 95% confidence intervals (CIs), and the Kaplan-Meier estimator was used to estimate absolute risks. Additionally, we calculated the 5-year restricted mean survival times (RMST) and the 5-year RMST difference between dialysis and conservative care arms. To test the robustness and consistency of our main results, we performed a subgroup analysis in patients aged ≥80. Results Of 2834 eligible patients, 1903 had a registered choice for dialysis and 931 for conservative care. The median age was 81 years, 36.1% were female and median eGFR was 13.1 ml/min/1.73 m2. During the 5-year follow-up period, 29 conservative care patients started dialysis and 430 patients died before starting dialysis. After weighting, all confounders were balanced (standardized mean difference &amp;lt; 0.10). Compared to dialysis, conservative care was associated with a higher absolute 5-year risk of death (91.8% vs. 74.1%), corresponding with an absolute risk difference of 17.6% (95% CI 13.3%-21.9%) (Fig. 1). The adjusted hazard ratio for conservative care vs. dialysis was 2.3 (95% CI 2.0-2.6). The 5-year restricted mean survival times were 34.8 (95% CI 33.2-37.3) months for dialysis and 21.5 (95% CI 19.4-23.6) months for conservative care groups. The 5-year RMST difference was 13.3 months (95% CI 10.8-16.6), meaning that dialysis patients would live on average 13.3 months longer over a 5-year follow-up period than conservative care patients (Table 1). The results were consistent among people ≥ 80 years (adjusted HR 2.2, 95% CI 1.9-2.5; 5-year RMST difference 9.4 months, 95% CI 7.2-13.9). Conclusion In older patients with advanced CKD under nephrologist care, conservative care was associated with a higher risk of mortality than dialysis. These findings could improve the shared decision-making process with patients on the choice of kidney failure treatment.

Engaging Patients in Decision Making about Treatment of Kidney Failure: The Art and Science of Communication.

Engaging Patients in Decision Making about Treatment of Kidney Failure: The Art and Science of Communication.

Health care delivery of kidney transplantation to indigenous Māori in Aotearoa New Zealand: A qualitative interview study with clinician stakeholders.

Indigenous people experience higher rates of kidney failure than do non-Indigenous Peoples. However, compared to Indigenous patients, health care systems deliver kidney transplantation to non-Indigenous patients at a substantially higher rate and more frequently as the first treatment of kidney failure. Indigenous Māori patients in Aotearoa New Zealand report numerous barriers to kidney transplantation. We explore the perspectives of clinicians as stakeholders in the delivery of kidney transplantation. In 2021/2022 we conducted in-depth qualitative interviews with key stakeholder clinicians within kidney transplantation services in Aotearoa New Zealand, asking them about the issues for Māori patients. We used thematic analysis informed by critical theory to identify key findings and used structural coding to categorize the themes at the level of society, health system, and health services. We interviewed 18 clinicians (nine nephrologists, including two transplant nephrologists, and nine nurses, including six transplant coordinators). We identified nine themes from stakeholders related to delivery of kidney transplantation services to Māori patients and whānau (family), categorized according to three main levels: Firstly, at the level of society (the impact of colonization and distrust). Secondly, the health care system (failure to prevent and manage kidney disease, health care model delivers inequitable outcomes, and inadequate Māori health professional workforce). Thirdly, health care services (transplantation reliant on patient and family resources, complex assessment causes untimely delays, clinical criteria for transplantation, and lack of clinician ability to effect change). Delivery of kidney transplantation to Indigenous Peoples is impacted at the level of society, health care system, and health care service. To address inequities, a broad approach that addresses each of these levels is required.

Kidney Transplantation Improves Health-Related Quality of Life in Older Recipients.

Kidney transplantation is the best treatment for kidney failure in older patients. However, little is known regarding changes in health-related quality of life (HRQoL) from before to after transplantation and determinants of HRQoL in older kidney transplant recipients (KTR). We studied both, using data of older (≥65years) patients waitlisted for kidney transplantation and older KTR 1year after transplantation from the TransplantLines Biobank and Cohort Study. HRQoL was assessed using the SF-36 questionnaire. We included 145 older waitlisted patients (68% male, age 70 ± 4years) and 115 older KTR at 1year after transplantation (73% male, age 70 ± 4years). Both mental (48.5 ± 8.4 versus 51.2 ± 7.7, p = 0.009) and physical (47.4 ± 8.5 versus 52.1 ± 7.2, p < 0.001) HRQoL were higher among included KTR, compared to the waitlisted patients. In paired analyses among 46 patients with HRQoL-data both before and after transplantation, there was a trend towards increased mental HRQoL (49.1 ± 8.4 to 51.6 ± 7.5, p = 0.054), and significantly increased physical HRQoL (48.1 ± 8.0 to 52.4 ± 6.7, p = 0.001) after transplantation. Among all assessed factors, the number of patient-reported immunosuppressive drug-related side effects was most strongly negatively associated with both mental and physical HRQoL. In conclusion, HRQoL is significantly higher among older KTR after kidney transplantation compared to older waitlisted patients.

Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis.

Advances in the treatment of kidney failure with chronic dialysis have stagnated over the past three decades, with over 50% of patients still managed by conventional in-hospital haemodialysis. In parallel, the demands of chronic dialysis medical care have changed and evolved due to a growing population that has higher frailty and multimorbidity. Thus, the gap between the needs of kidney failure patients and the healthcare capability to provide effective overall management has widened. To address this problem, healthcare policy has increasingly aligned towards a human-centred approach. The paradigm shift of human-centred approach places patients at the forefront of decision-making processes, ensuring that specific needs are understood and prioritised. Integration of human-centred approaches with patient care has been shown to improve satisfaction and quality of life. The aim of this narrative is to evaluate the current clinical challenges for managing kidney failure for dialysis providers; summarise current experiences and unmet needs of chronic dialysis patients; and finally emphasise how human-centred care has advanced chronic dialysis care. Specific incremental advances include implementation of renal supportive care; home-assisted dialysis; hybrid dialysis; refinements to dialysis methods; whereas emerging advances include portable and wearable dialysis devices and the potential for the integration of artificial intelligence in clinical practice.

Post-Transplant Bone Disease in Kidney Transplant Recipients: Diagnosis and Management.

Kidney transplantation is the preferred gold standard modality of treatment for kidney failure. Bone disease after kidney transplantation is highly prevalent in patients living with a kidney transplant and is associated with high rates of hip fractures. Fractures are associated with increased healthcare costs, morbidity and mortality. Post-transplant bone disease (PTBD) includes renal osteodystrophy, osteoporosis, osteonecrosis and bone fractures. PTBD is complex as it encompasses pre-existing chronic kidney disease-mineral bone disease and compounding factors after transplantation, including the use of immunosuppression and the development of de novo bone disease. After transplantation, the persistence of secondary and tertiary hyperparathyroidism, renal osteodystrophy, relative vitamin D deficiency and high levels of fibroblast growth factor-23 contribute to post-transplant bone disease. Risk assessment includes identifying both general risk factors and kidney-specific risk factors. Diagnosis is complex as the gold standard bone biopsy with double-tetracycline labelling to diagnose the PTBD subtype is not always readily available. Therefore, alternative diagnostic tools may be used to aid its diagnosis. Both non-pharmacological and pharmacological therapy can be employed to treat PTBD. In this review, we will discuss pathophysiology, risk assessment, diagnosis and management strategies to manage PTBD after kidney transplantation.

Focus on Mitochondrial Respiratory Chain: Potential Therapeutic Target for Chronic Renal Failure.

The function of the respiratory chain is closely associated with kidney function, and the dysfunction of the respiratory chain is a primary pathophysiological change in chronic kidney failure. The incidence of chronic kidney failure caused by defects in respiratory-chain-related genes has frequently been overlooked. Correcting abnormal metabolic reprogramming, rescuing the "toxic respiratory chain", and targeting the clearance of mitochondrial reactive oxygen species are potential therapies for treating chronic kidney failure. These treatments have shown promising results in slowing fibrosis and inflammation progression and improving kidney function in various animal models of chronic kidney failure and patients with chronic kidney disease (CKD). The mitochondrial respiratory chain is a key target worthy of attention in the treatment of chronic kidney failure. This review integrated research related to the mitochondrial respiratory chain and chronic kidney failure, primarily elucidating the pathological status of the mitochondrial respiratory chain in chronic kidney failure and potential therapeutic drugs. It provided new ideas for the treatment of kidney failure and promoted the development of drugs targeting the mitochondrial respiratory chain.

The Point-of-Care Peritoneal Dialysis System Early Evaluation Study (POC-PDEE): A pilot proof-of-principal study of the Ellen Medical Devices Point-of-Care affordable peritoneal dialysis system.

The global unmet need for kidney replacement therapy means that millions of people die every year as they cannot afford treatment. Peritoneal dialysis (PD) offers comparable survival to haemodialysis and is often more affordable, but one barrier to increasing access is that conventional manufacturing and distribution of PD fluid is costly. Here we report the results from a pilot proof-of-principal study demonstrating for the first time that the Ellen Medical Devices Point-of-Care system can be used by patients to produce sterile PD fluid at the point-of-care. With further development, this low-cost system could offer a solution to the many millions of people around the world who currently cannot afford treatment for kidney failure.

Comparison of Kidney Graft Function and Survival in an Emulated Trial With Living Donors and Brain-Dead Donors.

Living donation (LD) transplantation is the preferred treatment for kidney failure as compared to donation after brain death (DBD), but age may play a role. We compared the 1-year estimated glomerular filtration rate (eGFR) after kidney transplantation for recipients of LD and DBD stratified by recipient and donor age between 2015 and 2018 in a matched cohort. The strength of the association between donation type and 1-year eGFR differed by recipient age (P interaction < 0.0001). For LD recipients aged 40-54years versus same-aged DBD recipients, the adjusted odds ratio (aOR) for eGFR ≥60mL/min/1.73m2 was 1.48 (95% CI: 1.16-1.90). For DBD recipients aged ≥ 60years, the aOR was 0.18 (95% CI: 0.12-0.29) versus DBD recipients aged 40-54years but was 0.91 (95% CI: 0.67-1.24) versus LD recipients aged ≥60years. In the matched cohort, 4-year graft and patient survival differed by donor age and type. As compared with DBD grafts, LD grafts increased the proportion of recipients with 1-year eGFR ≥60mL/min/1.73m2. Recipients aged ≥60years benefited most from LD transplantation, even if the donor was aged ≥60years. For younger recipients, large age differences between donor and recipient could also be addressed with a paired exchange program.

What are the observed procedural costs of vascular access surgery? Protocol for a systematic review

IntroductionA central component in the introduction of a novel surgical procedure or technique is an evaluation of its cost efficiency when compared with a benchmark standard of care. Accurate assessment...

Decision aids to assist patients and professionals in choosing the right treatment for kidney failure.

Kidney services vary in the way they involve people with kidney failure (PwKF) in treatment decisions as management needs change. We discuss how decision-science applications support proactively PwKF to make informed decisions between treatment options with kidney professionals. A conceptual review of findings about decision making and use of decision aids in kidney services, synthesized with reference to: the Making Informed Decisions-Individually and Together (MIND-IT) multiple stakeholder decision makers framework; and the Medical Research Council-Complex Intervention Development and Evaluation research framework. This schema represents the different types of decision aids that support PwKF and professional reasoning as they manage kidney disease individually and together; adjustments at micro, meso and macro levels supports integration in practice. Innovating services to meet clinical guidelines on enhancing shared decision making processes means enabling all stakeholders to use decision aids to meet their goals within kidney pathways at individual, service and organizational levels.

The relationship between quality of life and dietary fluid restriction non-adherence in hemodialysis patient

Hemodialysis is now the preferred method in the treatment of kidney failure. Patients who do not adhere to the diet during hemodialysis may experience negative changes in fluid-electrolyte balance. This study aimed to investigate the relationship between restricted fluid intake and the quality of life of hemodialysis patients in our country. The study was conducted with 186 hemodialysis patients, treated as outpatients in the hemodialysis unit of a university hospital in Samsun and as inpatients in the nephrology clinic. Data were collected using a questionnaire that included 23 questions on patients' sociodemographic and clinical characteristics, the SF-36 Short Quality of Life Scale, and the Dialysis Diet and Fluid Restriction Nonadherence Questionnaire. Kruskal-Wallis and Mann-Whitney U tests were used for analysis of quantitative data while Spearman correlation coefficient was used for correlation analysis. In line with the evidence obtained, it was established that there was a negative correlation between the status of non-compliance to dialysis diet and fluid restriction and the quality of life of individuals on hemodialysis treatment.&#x0D; Keywords: Diet; hemodialysis; fluid restriction; quality of life.

“We’re not There yet”: Exploring Contextual Factors Shaping Canadian Dialysis Nurses’ Engagement in Kidney Supportive Care

Abstract: Treatment for kidney failure, such as dialysis, can result in a tremendously high physical and psychosocial symptom burden on patients and their families. Kidney supportive care (KSC), including advance care planning, involves early identification and treatment of symptoms that improve the quality of life for people receiving dialysis. The delay or lack of engagement in KSC by dialysis nurses until the end of life may result in people dying without receiving optimal palliative care services. Purpose and Questions: Our overarching purpose is to develop a theory about the process of engagement in KSC by dialysis nurses, and this paper is about a sub-question: What are the personal, professional, organizational, and environmental factors that shape nurses’ attitudes/beliefs toward and knowledge of supportive care in dialysis? Methods: We followed Charmaz’s constructivist grounded theory method. Through initial purposeful and subsequent theoretical sampling, 23 nurses with work experience in outpatient hemodialysis, home hemodialysis, and peritoneal dialysis settings from across Canada were recruited to participate in two interviews, each using the Zoom© teleconferencing platform. Concurrent data collection and analysis were undertaken. Results: Findings at the focused coding stage comprise contextual factors impacting such engagement. The core category of Fragmenting Care is explained by four categories of contextual factors and their related concepts and sub-concepts: (1) structural (lack of dedicated time, language barrier, knowledge gap); (2) inter-relational (patient-related factors; nurse-related factors [discomfort with having the conversation, lack of self-confidence, multi-dimensional tensions—them versus us]); (3) cultural-dialysis (biomedical focus, ambiguous responsibility, inopportune conversations); and (4) systemic (lack of conceptual clarity). Implications: These collective factors have not been illuminated previously, and while challenging, they help to better understand and therefore address engagement in KSC by dialysis nurses. Conclusion: Effecting change to normalize KSC is a priority requiring solutions compatible with complex systems.

Immunological Approaches for Diagnosis and Treatment of Kidney Failure: A Systematic Review

Introduction: This section provides a brief overview of the significance of kidney failure and its impact on public health. It highlights the urgent need for effective diagnostic and treatment approaches to address this growing health concern. Overview of Immunological Mechanisms in Kidney Failure: The role of immune system dysregulation in the development and progression of kidney failure is discussed in this section. Various immune cells, cytokines, and inflammatory processes are explained in relation to their contribution to renal damage. Understanding these mechanisms is crucial for developing targeted interventions. Immunological Approaches for Diagnosis: This section reviews immunological markers or techniques used for diagnosing kidney failure. The advantages, limitations, and potential clinical applications of these markers or techniques are discussed. Accurate diagnosis plays a crucial role in timely intervention and management. Immunological Approaches for Treatment: Different immunotherapeutic strategies employed in managing kidney failure are explored in this section. The mechanisms of action, efficacy, and potential side effects associated with these approaches are discussed. Advancements in immunotherapy offer hope for improved patient outcomes. Challenges and Future Directions: Existing challenges in implementing immunological approaches for kidney failure diagnosis and treatment are addressed here. Additionally, potential areas of research are suggested to overcome these challenges and enhance patient outcomes. Identifying future directions will drive innovation and progress.

#3122 30-DAY COMPLICATIONS IN PERITONEAL DIALYSIS CATHETERS INSERTED PERCUTANEOUSLY VERSUS SURGICALLY IN A SECOND LEVEL HOSPITAL IN MERIDA, YUCATAN, MEXICO

Abstract Background and Aims Peritoneal dialysis (PD) catheter insertion technique has an impact on the health outcomes and technical success in PD. The percutaneous technique allows for a bedside, minimally invasive and faster insertion without the need of using an operating room and general anesthesia. In 2021, Agarwal et. al reported that percutaneous insertion was associated with a 64% relative risk reduction (RRR) of early exit site infection and a 48% RRR of early peritonitis with no difference in terms of mechanical complications compared to the surgical technique [1]. The aim of our study was to describe the frequency of mechanical and infectious complications within the first 30 days of PD catheter insertion between the percutaneous and surgical technique. Method We conducted a descriptive and prospective study in our Hospital from January 1st to December 31st, 2022. Patients who were candidates for renal replacement therapy with PD and who had no previous history of abdominal surgery or only minor abdominal surgery, underwent percutaneous insertion of PD catheter by a nephrologist with a bedside blind technique, whereas patients with previous abdominal surgery underwent surgical insertion with a mini laparotomy. Informed consent and preoperative blood tests were obtained before the procedure in both techniques. Patient preparation for the percutaneous insertion included fasting the night before, colonic enema and the placement of a urinary catheter, patients received antimicrobial prophylaxis as well as analgesia and light sedation. Mechanical and infectious complications within the first 30 days after insertion of double cuff Tenckhoff catheters were registered. Results During the study period, 155 PD catheter insertions took place in our hospital, the majority of insertions were surgical (53.5% versus 46.4%) and happened in women (60.6%). The mean age of the population was 51.5 years and 70.3% of the participants were diabetic. Exit-site infection was significantly more frequent in the surgically placed PD catheters (10% versus 1%, p = 0.02), there was a tendency for more mechanical dysfunction in the surgical technique versus the percutaneous technique (14.4% versus 5.5%, p = 0.07) and transfer to hemodialysis was more frequent in the surgical insertion group (10.8% versus 1.3%, p = 0.01). There was no difference between peritonitis in both groups and the frequency of uncomplicated PD catheters (catheter survival without any complication) was similar in both techniques. Conclusion Bedside PD catheter insertion by the nephrologist using a percutaneous technique can be an easy, timely, safe and adequate procedure with comparable success to the surgical insertion. It may have the advantage of more efficient control of infectious and mechanical complications and what is more, this approach could reduce the cost of kidney failure treatment as it allows for the use of minimal material and human resources.

Kidney replacement therapy: Pros and Cons

Kidney replacement therapy (KRT) is a term used to encompass life-supporting treatments for kidney failure. Kidney replacement therapy except kidney transplantation replaces nonendocrine kidney functions in patients with kidney failure. Researchers have noted that dialysis, which is one of the most common KRT used, cannot compensate for all the tasks performed by a kidney, and thus the term ‘Kidney support therapy’ has been suggested to be a better name. Support of kidney function in modern times encompasses a wide array of methods and clinical scenarios, from the ambulatory patient to the critically ill. The ability to safely and routinely deliver ongoing organ support in the outpatient setting has, until recently, separated kidney replacement therapy from other organ support. Kidney replacement therapy (KRT) can be applied intermittently or continuously using extracorporeal (hemodialysis) or Para corporeal (peritoneal dialysis) methods. All modalities exchange solute and remove fluid from the blood, using dialysis and filtration across permeable membranes. Nearly 4 million people in the world are living on kidney replacement therapy(KRT),and haemodialysis (HD) remains the commonest form of KRT, accounting forapproximately 69% of all KRT and 89% of all dialysis. Continuous therapy although costly is used mainly for hemodynamically unstable patients; benefits over intermittent therapy are improved tolerability as a result of slower removal of solute and water. Kidney transplantation is the ultimate step for end stage kidney failure management, as it replaces native kidney function completely. The main disadvantages of KRT relate to: Catheter related complications – blood loss, disconnection, infection or failure of access, mechanical complications of the extracorporeal circuit, fluctuations in the salt-water balance, activation of the coagulation cascade. Specific complications of peritoneal dialysis include: peritonitis, catheter- associated infections, hyperglycemia, protein loss etc. Current trends in artificial kidney research are ongoing with the lofty goal of a small device, preferably implanted with little or no maintenance required by the wearer that would deliver safe and highly effective renal replacement therapy including metabolic and endocrine functions. Bangladesh J Medicine 2023; Vol. 34, No. 2(1) Supplement: 181

Value of patient decision aids for shared decision-making in kidney failure.

It is unknown how often Dutch patient decision aids are used during kidney failure treatment modality education and what their impact is on shared decision-making. We determined the use of Three Good Questions, 'Overviews of options', and Dutch Kidney Guide by kidney healthcare professionals. Also, we determined patient-experienced shared decision-making. Finally, we determined whether the experience of shared decision-making among patients changed after a training workshop for healthcare professionals. Quality improvement study. Healthcare professionals answered questionnaires regarding education/patient decision aids. Patients with estimated glomerular filtration rate <20 mL/min/1.73 m2 completed shared decision-making questionnaires. Data were analysed with one-way analysis of variance and linear regression. Of 117 healthcare professionals, 56% applied shared decision-making by discussing Three Good Questions (28%), 'Overviews of options' (31%-33%) and Kidney Guide (51%). Of 182 patients, 61%-85% was satisfied with their education. Of worst scoring hospitals regarding shared decision-making, only 50% used 'Overviews of options'/Kidney Guide. Of best scoring hospitals 100% used them, needed less conversations (p = 0.05), provided information about all treatment options and more often provided information at home. After the workshop, patients' shared decision-making scores remained unchanged. The use of specifically developed patient decision aids during kidney failure treatment modality education is limited. Hospitals that did use them had higher shared decision-making scores. However, the degree of shared decision-making experienced by patients remained unchanged after healthcare professionals were trained on shared decision-making and the implementation of patient decision aids.