Outpatient Hemodialysis Patients Research Articles

Impacts of Hospital Acquired Bloodstream Infections in Patients Undergoing Hemodialysis Through a Central Venous Catheter

Background: Hospital acquired infections (HAI) are of interest given their resultant morbidity, mortality, and hospital utilization. Among HAIs, central line associated bloodstream infections result in the highest rates of mortality and additional costs. While all central venous catheters (CVC) carry risk for BSI, long-term catheter use is at increased risk. One population that utilize CVCs for extended durations are those undergoing hemodialysis. While data are available characterizing BSI impacts on outpatient hemodialysis patients, little data exist describing inpatients. The purpose of this study was to characterize the demographics, outcomes, and economics associated with the development of hospital acquired BSI (HA-BSI) in patients undergoing hemodialysis through a CVC (HD-CVC). Methods: All admissions of adult patients in the Premier Healthcare Database with hospital stays including HD-CVC with discharge dates during 2020-2022 were retrospectively evaluated. BSIs were identified by ICD-10 codes and blood culture collection dates. A BSI was deemed hospital acquired if the blood culture date was ≥3 calendar days after admission. Descriptive analyses were undertaken for HA-BSI patients including: baseline demographics, clinical characteristics, and outcomes. Length of stay (LOS), ICU utilization, and estimated costs were evaluated for HAI-BSI and non-BSI populations. Results: 166,394 admissions from 91,448 patients were identified. Of these, 5,722 patients (6.3%) had 5,842 admissions with a HA-BSI. These patients were 58.9% white, 28.3% black, 56.8% male, and 62.9% were aged ≥60years. Patients had considerable comorbidities at baseline with 88.9% having ≥2 Charlson comorbid conditions and 46.9% with ≥6. During the study period, all-cause mortality was 27.8% for HA-BSI patients with 85.5% of deaths occurring while inpatient. Median LOS for patients with HA-BSI was 25 days compared with 6 days for HD-CVC without BSI; patients with HA-BSI were also more likely to require the ICU (65.6% vs. 27.6%). The median ICU LOS was 12 days for HA-BSI versus 34 days for HD-CVC without BSI. Greater intensity of healthcare utilization was reflected in median costs of $402K for HA-BSI, compared with $43K for HD-CVC without BSI. Discussion: We described the characteristics of HD-CVC patients that developed HA-BSI. These patients had many comorbidities and relatively high rates of all-cause in-hospital mortality. Patients were likely to have long LOS, both in-hospital and within the ICU. Collectively, care of these patients was associated with considerable healthcare costs, particularly as compared with HD-CVC patients not developing a HA-BSI. Future studies should characterize risk factors and evaluate potential prevention strategies for this high-risk population.

Characteristics of neutralizing antibody titers of the SARS-CoV-2 vaccine in maintenance hemodialysis patients.

Hemodialysis patients have high COVID-19 severity and mortality rates. For this high-risk group of hemodialysis patients with SARS-CoV-2 infection, early SARS-CoV-2 vaccination is recommended to prevent infection and severe disease. Thus far, few reports have evaluated COVID-19 antibody titers in hemodialysis patients. In this study, we investigated the time course of antibody titers acquired by vaccination in patients on dialysis. The anti-SARS-CoV-2 spike protein S1 IgG (anti-SP-IgG) antibody titers were compared between 33 outpatient maintenance hemodialysis patients and 32 age- and sex-matched healthy subjects. Antibody tests were performed at five time points: 6 months after the 2nd vaccination, immediately before the 3rd vaccination (8 months after the 2nd vaccination), and 2 weeks, 1 month, and 3 months after the 3rd vaccination. The dialysis patient group had significantly lower values of anti-SP-IgG antibody titers than the control group 6 months after the 2nd vaccination (433.7 ± 36.24 vs. 650.2 (427.2 - 759.4) (AU/mL), p = 0.006) and immediately before the 3rd vaccination (219.3 (129.4 - 423.4) vs. 443.3 (267.1 - 600.4) (AU/mL), p = 0.034), but no significant differences were observed after the 3rd vaccination (19,000.0 (11,000.0 - 3,6000.0) vs. 23,500.0 (20,250.0 - 29,000.0) (AU/mL), p = 0.538). This study confirmed that patients undergoing hemodialysis were proven to have acquired sufficient antibody titers after the vaccination.

Analysis of Socio-Demographic Factors Influencing Anxiety in Hemodialysis Patients

Background: Advanced chronic kidney disease patients need hemodialysis, the most used method of renal replacement therapy today. The patient will receive hemodialysis therapy for the rest of their life so that it can have a psychological effect like anxiety. Aims: This study aims to examine the socio-demographic variables affecting anxiety in hemodialysis patients. Method: This research used a cross-sectional analytical observational study design. A total sampling technique was used in this research. From 113 outpatient hemodialysis patients in March 2023, 80 samples of patients at Roemani Semarang Hospital met the inclusion and exclusion criteria. Inclusion criteria were patients undergoing hemodialysis at Roemani Semarang Hospital who were willing to participate in the study. Exclusion criteria were incomplete questionnaires, patients with impaired consciousness, patients with communication disorders, and patients using anti-anxiety medication. The information collected was primary information from questionnaires and interviews. The data were tested using the Spearman test with a significance level of p<0.05 for age and family support, and the chi-square test for gender, employment, and educational status. Results: The statistical analysis showed a p-value of 0.704 for age, a p-value of 0.020 for gender, a p-value of 0.558 for employment, a p-value of 0.138 for educational level, and a p-value of 0.000 for family support. Conclusion: The results showed a significant relationship between gender and family support with anxiety levels. The higher the family support, the lower the anxiety level. There is no relationship between age, employment, and education level with the anxiety level of patients undergoing hemodialysis at Roemani Semarang Hospital.

Evaluating the Impact of a Tailored Electronic Medication Management System on Anemia Management in Outpatient Hemodialysis Patients

Evaluating the Impact of a Tailored Electronic Medication Management System on Anemia Management in Outpatient Hemodialysis Patients

#3194 THE IMPACT OF COVID-19 PANDEMIC ON PSYCHOLOGICAL AND SOCIOECONOMIC WELL-BEING OF HEMODIALYSIS PATIENTS: AN ANALYTICAL CROSS-SECTIONAL STUDY

Abstract Background and Aims This study aimed to determine and assess the prevalence of depression, anxiety, and stress of the COVID-19 pandemic among outpatient hemodialysis patients and the relationship to sociodemographic and clinical factors, and to assess the economic impact of the COVID-19 pandemic. Method In this analytical, cross-sectional study, purposive sampling was used and a total of 69 subjects were enrolled. Sociodemographic data were collected using researcher-administered questionnaires and recent laboratory parameters were collected by reviewing medical records. Patients completed 4 sets of questionnaires including Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder 7 (GAD-7), Perceived Stress Scale 4 (PSS-4), and CoRonavIruS Health Impact Survey (CRISIS). Quantitative variables were presented using mean and standard deviation, median, and Interquartile Range (IQR). Qualitative variables were presented using frequency and percentages. Pearson's correlation was used to determine the relationship of laboratory parameters with anxiety, depression, and stress scores. The Chi-Square test was used to determine the relationship of sociodemographic profile with anxiety, depression, and stress scores. P values <0.05 were considered statistically significant. Results Our study showed that the prevalence of anxiety, depression, and stress were 39%, 16%, and 51% respectively. There was an association between age and stress level, with older subjects reporting higher stress scores. Hemoglobin levels had a weak negative correlation with anxiety, depression and stress. The distribution of anxiety scores was significantly different between patients with normal phosphorus levels and elevated phosphorus levels. Financial worries were less of a concern since almost two-thirds of our subjects were retired and unemployed. Conclusion Hemodialysis patients belong to high-risk populations with a high prevalence of psychological distress hence they are subjected to more severe psychological stress, depression, and anxiety. Our findings suggest that psychological intervention may be necessary for some patients during this pandemic.

Electronic Decision Support for Deprescribing in Patients on Hemodialysis: Clinical Research Protocol for a Prospective, Controlled, Quality Improvement Study.

Patients on dialysis are commonly prescribed multiple medications (polypharmacy), many of which are potentially inappropriate medications (PIMs). Potentially inappropriate medications are associated with an increased risk of falls, fractures, and hospitalization. MedSafer is an electronic tool that generates individualized, prioritized reports with deprescribing opportunities by cross-referencing patient health data and medications with guidelines for deprescribing. Our primary aim was to increase deprescribing, as compared with usual care (medication reconciliation or MedRec), for outpatients receiving maintenance hemodialysis, through the provision of MedSafer deprescribing opportunity reports to the treating team and patient empowerment deprescribing brochures provided directly to the patients themselves. This controlled, prospective, quality improvement study with a contemporary control builds on existing policy at the outpatient hemodialysis centers where biannual MedRecs are performed by the treating nephrologist and nursing team. The study takes place on 2 of the 3 outpatient hemodialysis units of the McGill University Health Centre in Montreal, Quebec, Canada. The intervention unit is the Lachine Hospital, and the control unit is the Montreal General Hospital. A closed cohort of outpatient hemodialysis patients visit one of the hemodialysis centers multiple times per week for their hemodialysis treatment. The initial cohort of the intervention unit includes 85 patients, whereas the control unit has 153 patients. Patients who are transplanted, hospitalized during their scheduled MedRec, or die before or during the MedRec will be excluded from the study. We will compare rates of deprescribing between the control and intervention units following a single MedRec. On the intervention unit, MedRecs will be paired with MedSafer reports (the intervention), and on the control unit, MedRecs will take place without MedSafer reports (usual care). On the intervention unit, patients will also receive deprescribing patient empowerment brochures for select medication classes (gabapentinoids, proton-pump inhibitors, sedative hypnotics and opioids for chronic non-cancer pain). Physicians on the intervention unit will be interviewed post-MedRec to determine implementation barriers and facilitators. The primary outcome will be the proportion of patients with 1 or more PIMs deprescribed on the intervention unit, as compared with the control unit, following a biannual MedRec. This study will build on existing policies aimed at optimizing medication therapy in patients undergoing maintenance hemodialysis. The electronic deprescribing decision support tool, MedSafer, will be tested in a dialysis setting, where nephrologists are regularly in contact with patients. MedRecs are an interdisciplinary clinical activity performed biannually on the hemodialysis units (in the Spring and Fall), and within 1 week following discharge from any hospitalization. This study will take place in the Fall of 2022. Semi-structured interviews will be conducted among physicians on the intervention unit to determine barriers and facilitators to implementation of the MedSafer-supplemented MedRec process and analyzed according to grounded theory in qualitative research. Deprescribing can be limited due to nephrologists' time constraints, cognitive impairment of the hemodialyzed patient stemming from their illness and complex medication regimens, and lack of sufficient patient resources to learn about the medications they are taking and their potential harms. Electronic decision support can facilitate deprescribing for the clinical team by providing a nudge reminder, decreasing the time it takes to review and effectuate guideline recommendations, and by lowering the barrier of when and how to taper. Guidelines for deprescribing in the dialysis population have recently been published and incorporated into the MedSafer software. To our knowledge, this will be the first study to examine the efficacy of pairing these guidelines with MedRecs by leveraging electronic decision support in the outpatient dialysis population. This study was registered on Clinicaltrials.gov (NCT05585268) on October 2, 2022, prior to the enrolment of the first participant on October 3, 2022. The registration number is pending at the time of protocol submission.

Associations of Iron Sucrose and Intradialytic Blood Pressure

Intradialytic hypotension and intradialytic hypertension are associated with morbidity and mortality in hemodialysis (HD). Many factors can contribute to intra-HD blood pressure (BP) changes, such as drugs with vasoactive properties that can destabilize an already tenuous BP. Intravenous iron sucrose is commonly administered to correct iron deficiency; however, its reported associations with altered hemodynamics have not been consistent. Prospective cohort study. 950 outpatients receiving maintenance HD. Iron sucrose administered during HD. Intradialytic hypotension, intradialytic hypertension, systolic blood pressure parameters. Unadjusted and adjusted Poisson and linear repeated measures regression models. The mean age of patients included in the study was 53±22 years, 43% were female, and 38% were Black. Mean pre-HD SBP was 152±26 (SD) mm Hg. At baseline, the patients who received higher doses of iron sucrose tended to have diabetes, have longer HD sessions, and have a higher frequency of erythropoiesis-stimulating agent use, compared with those who did not receive iron sucrose. In adjusted models, higher doses of iron sucrose were associated with an 11% lower rate of intradialytic hypotension (incidence rate ratio [IRR] for iron sucrose≥100mg vs 0 mg, 0.89 [95% CI, 0.85-0.94]). In adjusted analyses, the administration of higher doses of iron sucrose during HD was associated with intradialytic hypertension (IRR for iron sucrose≥100mg vs 0 mg, 1.07 [95% CI, 1.04-1.10]). Nonavailability of the precise iron sucrose formulation (volume), laboratory data for each HD session, and outpatient medications. Objective measures of volume status, home medications, and symptom data were not recorded in this study. We observed an independent association of intravenous iron sucrose administration during HD with a lower risk of intradialytic hypotension and higher risk of intradialytic hypertension. Future studies to better understand the mechanisms underlying these associations are warranted. Intradialytic hypotension and intradialytic hypertension are common among patients on hemodialysis, and they are associated with morbidity and mortality. Although many factors may contribute to these risks, medications administered during hemodialysis play an important role. We studied the significance of the intravenous iron sucrose used to treat iron deficiency and the impact it may have on blood pressure during dialysis. In our study of 950 outpatient hemodialysis patients, we observed that administration of iron sucrose was associated with higher systolic blood pressure (during and after hemodialysis sessions) as well as a lower risk of intradialytic hypotension. We also observed that higher doses of iron sucrose are associated with the development of intradialytic hypertension.

Validation of an instrument to assess fluid control in outpatient hemodialysis patients

Purpose: To validate an instrument to assess fluid control in outpatient hemodialysis patients, using the NANDA International (NANDA-I), Nursing Interventions Classification (NIC), and Nursing Outcomes Classification (NOC) terminologies.Methods: A methodological study was carried out in two steps: (1) construction of an instrument composed of operational definitions of the defining characteristics of the nursing diagnosis Excess fluid volume, indicators of the NOC outcome Fluid balance, and activities of the NIC intervention Fluid management, from a narrative literature review, and (2) content validation of the instrument by five experts through a focus group.Results: The instrument was composed of operational definitions of 27 defining characteristics of Excess fluid volume, 23 Fluid balance indicators, and 13 Fluid management activities. Twenty-five out of the 27 defining characteristics were considered valid. Two defining characteristics were excluded from the instrument, as they were considered unsuitable for assessing outpatients on hemodialysis. Thirteen out of the 23 indicators of Fluid balance were reformulated, and two were removed. Thirteen activities of Fluid management were reformulated.Conclusions: An instrument was built incorporating components of the nursing diagnosis Excess fluid volume, the nursing outcome Fluid balance, and the nursing intervention Fluid management. The instrument was considered valid in terms of content and can be used to assess outpatients on hemodialysis. Implications for nursing practice: The instrument created may contribute to the standardization, qualification, and improvement of nursing practice in outpatient hemodialysis facilities.

Rates of intravenous antibiotic starts among outpatient hemodialysis patients using NHSN dialysis event reporting, 2016–2020

Background: Nearly one-third of patients on hemodialysis receive intravenous (IV) antibiotics annually, but national data characterizing antibiotic use in this population are limited. Using NHSN surveillance data for outpatient dialysis facilities, we estimated temporal changes in the rate of IV antibiotic starts (IVAS) among hemodialysis patients as well as the proportion of IVAS that were not supported by a reported clinical indication. Methods: IVAS events were obtained from the NHSN Dialysis Event module between 2016 and 2020, excluding patients who were out of network, receiving peritoneal or home dialysis, or with unspecified vascular access. IVAS unsupported by documentation were defined as new IVAS without a collected or positive blood culture, pus, redness or swelling event, or an associated clinical symptom. Pooled mean rates of total and unsupported IVAS were estimated per 100 patient months yearly and stratified by vascular access type. Differences in IVAS rates by year were estimated with negative binomial regression. Results: Between 2016 and 2020, 7,278 facilities reported 648,410 IVAS events; 161,317 (25%) were unsupported by documentation (Table 1). In 2016, 3,340 (54%) facilities with ≥1 IVAS event reported an IVAS unsupported by documentation, which increased to 4,994 (73%) in 2020. Total IVAS rates decreased by an average of 8.2% annually (95% CI, 7.1%–9.3%; P < .001). The average annual percentage decrease did not differ significantly by vascular access site. The total IVAS rate was lowest in 2020 (2.17 per 100 patient months; 95% CI, 2.18–2.17). IVAS rates in 2020 were greatest for patients with catheter access (4.79 per 100 patient months; 95% CI, 4.75–4.83), followed by graft (1.71 per 100 patient months; 95% CI, 1.68–1.73), and lowest for patients with fistulas (1.30 per 100 patient months; 95% CI, 1.29–1.31). The overall pooled mean rate of unsupported IVAS was 0.64 per 100 patient months (95% CI, 0.63–0.64), which did not significantly change by year (Fig. 1). Conclusions: Total IVAS rates among outpatient hemodialysis patients have decreased since 2016, and rates among catheter patients remain highest compared to patients with fistulas or grafts. However, unsupported IVAS rates did not change, and the proportion of facilities reporting an unsupported IVAS increased annually. Targeted efforts to engage facilities with unsupported IVAS may help improve accurate reporting and prescribing practices.Funding: NoneDisclosures: None

Relationships among the Nutritional Risk Index for Japanese Hemodialysis Patients, Geriatric Nutritional Risk Index, Motor Function and Skeletal Muscle Mass Index in Outpatient Maintenance Hemodialysis Patients: A Retrospective Observational Study

[Purpose] To investigate the relationships among the Nutritional Risk Index for Japanese Hemodialysis Patients (NRI-JH), Geriatric Nutritional Risk Index (GNRI), motor function and Skeletal Muscle Mass Index (SMI), and to examine the usefulness of NRI-JH. [Participants and Methods] Sixty outpatients (38 males and 22 females) on maintenance hemodialysis were included in the study. Basic characteristics such as age, gender, height, dry weight, Body Mass Index, NRI-JH score, GNRI, hand-grip strength (HGS), five times sit-to-stand test, and SMI were used as assessment items. [Results] The NRI-JH score was not significantly related to any of the items, and the GNRI was positively related to SMI and HGS. [Conclusion] The NRI-JH score was not related to GNRI or motor function. A limitation of this study was the limited number of subjects. Future studies are needed to examine the associations of the NRI-JH with nutritional screening, exercise function, and SMI.

MO892DIALYSIS SERVICE MANAGEMENT DURING COVID-19 PANDEMIC IN EUROPEAN CITY AREA

Background and AimsMany countries across Europe experience the second wave of CoVid-19 pandemic. Lithuania is a country situated on the eastern shore of the Baltic Sea. Until January 15, Lithuania had 165560 confirmed positive cases, 100495 recoveries, and 2376 deaths.MethodIn this abstract, we describe reorganization in dialysis service in Vilnius, the capital and largest city of Lithuania, with urban population of 700,275 inhabitants.ResultsAt the pandemic start in March 2020, Vilnius had 3 public nephrology departments each running a hemodialysis unit, and 4 private hemodialysis centers, with total of 250 end-stage kidney disease patients. Vilnius University Hospital Santaros Klinikos, as the main hospital in the country and national CoVid-19 coordinator, restructured dialysis service in city area. Chronic hemodialysis programs in public hospitals were cancelled and patients were shifted to private centers. In the threat of infection and multiple outbreaks in two hospitals, nephrology units were closed and CoVid-19 negative nephrology patients were located in a satellite hospital in other city, whilst all city hospitals served as CoVid-19 centers. In Santaros Klinikos, we treated severe CoVid-19 patients who needed chronic or acute dialysis, while asymptomatic and mild to moderate-symptom patients carried their dialysis procedures in isolated shafts and/or facilities in private centers. In cases with unsatisfactory self-isolation, isolation sites were located in hotels or other premises provided by the municipal administration. Transportation to dialysis center was provided by municipality as well. Rapid antigen testing was set in a case of suspected outbreak or for all outpatient hemodialysis patients in some centers in circumstances of high community transmission. During the pandemic, we had ongoing transplant activities, continued wait-listing for kidney transplant and increased peritoneal dialysis program. Most peritoneal dialysis patients were trained at home by a mobile nurse team, also home visits we carried instead of inpatients visits. We started CoVid-19 vaccination during the first week of January for all dialysis patients and transplant recipients who had no contraindications and gave informed consent.ConclusionIn conclusion, the rapid release and adoption of recommendations and action plan helped to identify and locate CoVid-19 outbreaks in dialysis facilities. Dialysis service reorganization is needed to maintain ongoing treatment for chronic patients who vitally depend on renal replacement therapy. Private dialysis centers and municipality should assist with physical resources operating the patients flow. The growth of peritoneal dialysis program serves as a significant subsidiary factor when patients need more social distancing. Vaccination data and outcomes in end-stage renal disease patients is coming soon.

COVID-19 Antibodies and Outcomes among Outpatient Maintenance Hemodialysis Patients.

Patients on maintenance hemodialysis are particularly vulnerable to infection and hospitalization from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Due to immunocompromised patients and the clustering that occurs in outpatient dialysis units, the seroprevalence of COVID-19 antibodies in this population is unknown and has significant implications for public health. Also, little is known about their risk factors for hospitalization. Three outpatient maintenance hemodialysis units affiliated with a major teaching hospital in the New York area were studied. We determined rates of SARS-CoV-2 positivity via nasopharyngeal, real-time, reverse-transcriptase PCR (RT-PCR); SARS-CoV-2 IgG seropositivity; hospitalization; and mortality. Of 367 patients, 28% had either SARS-CoV-2 seropositivity or PCR positivity. Prevalence across the three respective units was 7%, 32%, and 70%. Those who were either antibody or PCR positive were significantly younger (65 versus 69 years, P=0.05), and had a higher prevalence of Black race (43% versus 30%, P=0.001) and Hispanic ethnicity (32% versus 12%, P<0.001) compared with those who tested negative. Higher positivity rates were also observed among those who took taxis and ambulettes to and from dialysis, compared with those who used personal transportation. Antibodies were detected in all of the patients with a positive PCR result who underwent serologic testing. Of those that were seropositive, 32% were asymptomatic. The hospitalization rate on the basis of either antibody or PCR positivity was 35%, with a hospital mortality rate of 33%. Aside from COPD, no other variables were more prevalent in patients who were hospitalized. We observed significant differences in rates of COVID-19 infection within three outpatient dialysis units, with universal seroconversion. Among patients with ESKD, rates of asymptomatic infection appear to be high, as do hospitalization and mortality rates.

Efficacy of ferumoxytol versus sodium ferric gluconate in anemia management in outpatient hemodialysis patients: Aprospective cohort study.

Intravenous iron is one of the main therapies for anemia management in hemodialysis-dependent patients. Data comparing the efficacy of ferumoxytol versus other parenteral iron supplements are scarce. The objective of the study was to compare the efficacy of ferumoxytol with that of sodium ferric gluconate in outpatient hemodialysis patients. A prospective, observational study was conducted in outpatients receiving ferumoxytol 510mg once or twice quarterly compared to sodium ferric gluconate 125mg weekly in a single center hemodialysis center in Ontario, Canada. Patient demographics, hemoglobin levels, iron indices, iron doses, and erythropoiesis-stimulating agent (ESA) doses were collected. The study sample consisted of 291 observations from 173 patients. Generalized estimating equations of multiple linear regression modeling were conducted to compare the outcomes while adjusting for baseline scores. Approximately 25% of the study participants received ferumoxytol while 75% received sodium ferric gluconate. Patients treated were mainly males (58.4%), and the mean age was 68.73 (SD±13.03) years. Both groups did not show significant differences in their hemoglobin levels (Wald z=0.54; p=0.46), ESA utilization at 3 months (Wald z=0.20; p=0.65), and TSAT levels (Wald z=3.45; p=0.06). However, the iron levels (Wald z=4.24; p=0.04) and ferritin levels (Wald z=5.14; p=0.02) were higher in the ferric gluconate group (Wald z=58.78; p≤0.001), and patients who received ferumoxytol received more blood transfusions as compared to those who received sodium ferric gluconate (χ2=16.71; p≤0.001). Both iron products maintained hemoglobin levels, but patients receiving ferumoxytol had lower iron indices and received more blood transfusions compared to patients who received sodium ferric gluconate.

A mixed-methods feasibility study of an arts-based intervention for patients receiving maintenance haemodialysis

BackgroundHaemodialysis can negatively impact quality of life and mental health. Arts-based interventions used successfully in other settings to improve health and well-being, could help address the impact of haemodialysis. This study aimed to evaluate the feasibility and acceptability of conducting a randomised controlled trial (RCT) of an arts-based intervention for patients receiving haemodialysis.MethodsA parallel convergent mixed-methods design was used, including a pilot cluster RCT and qualitative process evaluation.Phase 1 evaluated recruitment and retention rates through a pilot cluster RCT at a single haemodialysis unit in Northern Ireland. Participants included patients who received haemodialysis for ESKD, were over the age of 18 and had the capacity to consent. These participants were randomised to the intervention or control group according to their haemodialysis shift. The intervention involved six one-hour, one-to-one facilitated arts sessions during haemodialysis.Phase 2 explored intervention and trial acceptability through a qualitative process evaluation using semi-structured interviews based on the RE-AIM framework. Participants included 13 patients who participated in phase 1 of the study, including 9 participants from the experimental group and four participants from the control group, and nine healthcare professionals who were present on the unit during implementation.ResultsOut of 122 outpatient haemodialysis patients, 94 were assessed as eligible for participation. Twenty-four participants were randomised, meaning 80% of the target sample size was recruited and the attrition rate at 3 months was 12.5% (n = 3). Participants viewed the arts as more accessible and enjoyable than anticipated following implementation. All participants who started the intervention (n = 11) completed the full six sessions. Qualitative benefits of the intervention suggest improvements in mental well-being. Patient choice and facilitation were important factors for successful implementation.ConclusionAn arts-based intervention for patients receiving haemodialysis is acceptable for both patients and healthcare professionals, and a definitive trial is feasible. The intervention may help improve mental-wellbeing in patients receiving haemodialysis, but this requires further investigation in a definitive trial.Trial registrationThe trial was prospectively registered on clinicaltrials.gov on 14/8/2018, registration number NCT03629496.

Effective prevention and management of COVID-19 in outpatient hemodialysis patients.

The authors introduce a mobile phone app that may effectively prevent and manage coronavirus disease 2019 (COVID-19) in outpatient hemodialysis patients in Sichuan Province, China.

Intradialytic exercise in the treatment of social frailty: a single-center prospective study\u2014preliminary results during the unexpected COVID-19 pandemic

BackgroundSocial frailty—the lack of a connection to society and infrequent social activities—has been reported to be associated with future declines in physical function in elderly individuals. This study aimed to evaluate both the association of social frailty with the physical function and the efficacy of intradialytic exercise as a therapy for social frailty among hemodialysis patients.MethodsAll 16 outpatient hemodialysis patients in the hemodialysis department of a single medical center were enrolled in this single-center prospective single-arm interventional study. Patients received five questions which asked about going out infrequently, lack of visiting friends, feeling unhelpful to friends or family, living alone, and lack of talking with someone. Those to whom two or more of the above were applicable were categorized as socially frail. All patients were placed into exercise therapy to be performed during their thrice-weekly hemodialysis visits. Participants’ physical function (walking speed), muscle strength (grip strength), muscle mass (appendicular skeletal muscle mass index), and social frailty were evaluated at baseline and after 3 months of therapy.ResultsFour (25%) of the 16 participants (median age 71.5 years, 8 women) were categorized as being socially frail. In comparison to the non-socially frail group (non-SF), the socially frail group (SF) had a significantly lower walking speed (0.70 ± 0.12 m/s vs 1.15 ± 0.26 m/s, p = 0.005) and significantly worse performance on the Short Physical Performance Battery. Three months of intradialytic exercise therapy significantly improved their walking speed, from 1.04 ± 0.30 m/s to 1.16 ± 0.29 m/s (p = 0.003). intradialytic exercise therapy significantly improved walking speed in both the SF group and the non-SF group. The 2019 coronavirus disease pandemic unexpectedly occurred in the middle of the intervention period of this study, and although it was not statistically significant, the number of socially frail individuals among our participants increased to seven (43.8%, p = 0.248).ConclusionsSocial frailty was associated with reduced physical function among hemodialysis patients. Intradialytic exercise therapy improved physical function regardless of the presence of social frailty.Trial registrationUMIN-CTR, UMIN-CTR000038313. Registered November 1, 2019, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000043639.

Home Dialysis in the Coronavirus Disease 2019 Era.

The coronavirus disease 2019 pandemic has had a significant impact on patients with end-stage kidney disease and their care, especially given the potential for severe coronavirus disease 2019 in those with a depressed immune status. Patients receiving in-center hemodialysis have been particularly affected by this pandemic because of their need to travel multiple times a week to receive treatment. Although patients on home dialysis are able to avoid such exposure, they face their own unique challenges. In this review, we will discuss the challenges posed by the coronavirus disease 2019 pandemic for patients on home dialysis, the impact of coronavirus disease 2019 on various aspects of their care, and the resultant rapid adaptations in policy/health-care delivery mechanisms with implications for the future care of patients on home dialysis.

Role of nephrology pharmacists in the management of anemia in outpatient dialysis units: A Canadian model .

Hemodialysis patients frequently suffer from anemia. Proper utilization of therapies such as iron and erythropoiesis-stimulating agents (ESAs) is crucial to attain symptom management and established hemoglobin targets. The purpose of this study was to evaluate the clinical and financial impact of nephrology-trained pharmacists on anemia management in these patients. A retrospective study of outpatient hemodialysis patients observed between January 2010 and December 2011. In December 2010, pharmacists were tasked to manage anemia under a medical directive. Primary endpoints were compared across years using a mixed-effects model strategy. An unstructured random effects correlation matrix was utilized to capture patient-level variation in 2010 and 2011, separately. Of 202 patients identified, 163 contributed in both years, 57% were males, aged 65.18 ± 16.3 years. Hemoglobin levels were 10.95 ± 0.95 and 10.83 ± 0.94 g/dL in 2010 vs. 2011, respectively (p = 0.158), while the transfusion rate was 1.3% and 1.8%, respectively (p = 0.196). Ferritin levels of 273.5 ± 22 and 317.1 ± 12 ng/mL (p = 0.0019), iron saturation 0.30 ± 0.11 and 0.30 ± 0.05 (p = 0.838), and parenteral iron dose of 215.4 ± 100.2 and 317.1 ± 123.7 mg, respectively (p = 0.996), were identified. Finally, the average weekly ESA dose in 2010 was higher and trending up as compared to 2011 where it significantly trended down. The amount of intravenous erythropoietin alfa was 12,315.6 ± 76 vs. 11,364.1 ± 52 units/week, respectively (p = 0.0556) with expenditure of 2.8 million Canadian dollars in 2010 vs. 2.3 million Canadian dollars in 2011. The participation of a nephrology pharmacist resulted in favorable outcomes in dose optimization, decreased expenditure, and positive trends in therapeutic goal achievement.

Management of Hemodialysis Patients with Suspected or Confirmed COVID-19 Infection: Perspective of Two Nephrologists in the United States.

The coronavirus disease 2019 (COVID-19) pandemic is unprecedented and information about the severe acute respiratory syndrome coronavirus 2 is evolving rapidly. New York is one of the epicenters of the COVID-19 outbreak in the United States, reporting >1000 confirmed cases as of March 17, 2020, and cases are escalating exponentially. The majority of cases are in Westchester County ( n =220) and New York City (NYC; n =463), which includes Bronx (1). The local index patient case was a Westchester man who became ill on February 22, was not associated with a recent travel exposure to a country on the watch list (China, Iran, South Korea, and Italy), or known to have had direct contact with a COVID-19–confirmed patient. At the present time it is estimated that community-wide transmission accounts for 87% of confirmed cases. Nephrologists in the Bronx have been handicapped in managing patients with ESKD during the early weeks of the COVID-19 pandemic due to the limitations of available rapid testing for severe acute respiratory syndrome coronavirus 2. Montefiore Medical Center, located in the north Bronx in close proximity to Westchester, has been one of the main tertiary care hospitals in NYC caring for persons under investigation (PUIs) and for COVID-19–confirmed patients. Our nephrology division’s clinical faculty care for approximately 850 patients with ESKD (approximately 800 on hemodialysis and approximately 50 on peritoneal dialysis) in 12 outpatient hemodialysis facilities (two Fresenius and 10 DaVita facilities) in the Bronx. We report our experience with caring for the ESKD population and patients who are hospitalized with AKI in the Bronx during the first 3 weeks of the local NYC COVID-19 pandemic. Strategies proposed for the prevention and management of COVID-19 transmission for patients with ESKD in the outpatient dialysis facilities have been dynamic. The American Society of Nephrology’s (ASN’s) Nephrologists Transforming …

Identifying the nutritional profile of outpatient haemodialysis patients in Beaumont Hospital

AbstractBeaumont Hospital Kidney Centre, Dublin is currently the largest provider of haemodialysis in Ireland. There is a dedicated renal dietetic team to address the nutritional needs of these patients. In order to provide an optimal service, a thorough understanding and insight of the service demands is needed. Currently there is no nutritional profile of these patients. Similarly the Renal dietetic team have not been in a position to identify if they are meeting current best practice guidelines, as outline by the National Kidney Foundation. E-Med, an online renal electronic notes system, was used to provide all dietetic notes during 2018. Using an audit template, an audit of these notes for outpatient haemodialysis patients was carried out to identify a number of nutritional issues. 75% (123/163) of outpatient haemodialysis patients received direct dietetic intervention in 2018. 76% of these patients demonstrated more than one nutritional issue and 16% displayed more than five nutritional issues. The most prevalent nutritional issues arising were hyperkalemia (41%) and hyperphosphatemia (33%). Currently guidelines, which recommend a dietetic review, every 3–4 months are not being met. 53% of patients received either none or only one direct dietetic intervention in this time period. The recommended ratio of 1:100 (dietitian: haemodialysis patient) is also not being met. Currently the ratio stands at 1:243 as the dietitian responsible for haemodialysis patients is also responsible for peritoneal dialysis patients. The average length of time recorded for each direct intervention was 1 hour. Beaumont Hospital haemodialysis outpatient cohort is a nutritionally complex group of patients, which require ongoing and frequent dietetic input. Beaumont Hospital renal dietitians are successfully providing at least one episode of direct intervention to the majority (75%) of the outpatient haemodialysis patients, suggesting efficient and effective use of available resources. An increase in dietetic staffing for the renal service could offer the potential to provide direct dietetic input to all haemodialysis patients within the hospital and to also provide an increased number of reviews to patients, as per guidelines. It is possible that the amount of time spent on dietetic patient assessments is being under-reported and further work is needed to cross-reference these figures using an alternative statistical package.