Pre-dialysis Clinic Research Articles

A qualitative analysis of eating behaviour change for patients with diabetes and non-dialysis dependent chronic kidney disease stages 4-5.

Dietary changes recommended for chronic kidney disease (CKD) stages 4-5 and concurrent diabetes are difficult to follow given the multitude of food and fluid restrictions aimed at reducing the rate of CKD progression. Reduced adherence is commonplace and there is limited literature on patients' experiences with dietary changes and potential strategies to overcome this. Examine patients' experiences when adopting dietary changes recommended for CKD Stages 4-5 (pre-dialysis) and diabetes, and their perceptions of dietetic services and how they can be improved to assist them with dietary change. An exploratory qualitative study was undertaken using a purposive sampling method from a dietetic pre-dialysis clinic. Participants were interviewed using a semi-structured interview style. Data were analysed using an inductive thematic analysis from a constructivist perspective. Three themes were identified: (1) Negative motivation to change eating behaviour to avoid dialysis; (2) sustaining motivation for change is challenging due to a sense of loss and confusion to incorporate the dietary changes recommended and (3) support is needed for eating behaviour change. These findings have implications for dietitians to enhance their understanding of the patient experience and improve their skills in motivational counselling. Development of dietitian-specific communication and nutrition counselling programmes are recommended to equip dietitians with skills to better support patients. CKD Stage 3 nutrition education programmes could be beneficial to promote earlier access to dietetic services and dietary recommendations.

Haemodialysis vascular access: current practices amongst Indian nephrologists.

Despite the growing number of haemodialysis (HD) patients in India, little is known about vascular access practice. We investigated the use and cost of different vascular accesses by Indian nephrologists. An online survey was emailed to 920 Indian nephrologists and 388 (42.1%) responded; 98.5% of whom were responsible for managing dialysis patients, 98% in hospitals. Sixty-four percent of patients initiated renal replacement therapy with HD, 7% with peritoneal dialysis, 10% kidney transplantation and 19% conservative care. Forty-eight percent of patients were self-paying, 26% had employee reimbursement and 23% had insurance. According to 59% of responders, more than three-quarters of patients started dialysis with uncuffed catheter, less than one-quarter started dialysis with fistula; and very few used grafts or tunnelled catheters. Among prevalent HD patients, over half were dialysing with fistula (79% nephrologists), rather than uncuffed catheters (15% nephrologists) or grafts (<1% nephrologists). Sixteen percent reported at least one catheter-related sepsis in more than half of patients. Placement of uncuffed catheters cost US$160 in 92% facilities, whereas tunnelled catheters cost US$320 in 46% of facilities. An arteriovenous fistula (AVF) could be created for US$160 in 40%, and US$320 in 90% of centres. Thirty-five percent of nephrologists reported that grafts were not placed at their institute and where they were available, the average cost was over US$480. Forty-six percent of nephrologists had access to pre-dialysis clinics, <30% to vascular access programmes, and <17% conducted regular vascular access audits. The survey provides a snapshot of the current status of vascular access care in HD patients and highlights need for pre-dialysis clinics, vascular access services and registry audits.

Barriers to Peritoneal Dialysis in Aboriginal Patients.

Background:Aboriginal people in Canada have an unduly high burden of end-stage kidney disease (ESKD) and many live in rural settings. Peritoneal dialysis (PD) is a home-based dialysis modality that may provide a valuable alternative to in-center hemodialysis which is relatively underutilized by the Aboriginal population.Objective:We aim to assess the barriers to PD utilization in Aboriginal patients with ESKD.Design:This article is a prospective observational cohort study.Setting:The setting involves 3 predialysis clinics in Winnipeg, Kingston, and Moose Factory.Patients:The patients were 99 individuals (67 non-Aboriginal and 32 Aboriginal) who were at least 18 years of age with an estimated glomerular filtration rate of less than 30 mL/min/1.73m2, and were enrolled in one of the 3 study sites from April 2011 to October 2013.Measurements:Patient demographics and comorbidities were documented. Barriers to PD, PD as modality choice, and Aboriginal status were assessed via patient survey upon study enrollment. PD use as the initial dialysis modality was assessed via monthly patient follow-up for 1 year after enrollment in the study.Methods:The patient survey was created based on literature review of known barriers to PD, repaired based on direct patient feedback, and tested for reliability via the test-retest method. Differences in PD choice, barriers to PD, and PD use between Aboriginal and non-Aboriginal patients were determined by chi-square test and logistic regression.Results:All patients enrolled in the study completed the survey. Mean age was 65.5 versus 54.6 years for non-Aboriginals and Aboriginals, respectively. Barriers to PD significantly associated with Aboriginal status were lack of money (odds ratio [OR]: 21.3; 95% confidence interval [CI]: 5.3-86.4; P < .0001) and anxiety (OR: 2.8; 95% CI: 1.1-7.1; P = .03). There was no difference in PD choice between non-Aboriginals and Aboriginals (66.7% vs 68.8%, respectively; P = .83). One of 67 non-Aboriginals (1.5%) and 5 of 32 Aboriginals (15.6%) died prior to initiating dialysis (P = .013). No significant difference was observed between non-Aboriginals (33%) and Aboriginals (28%) in use of PD (P = .81).Limitations:Small sample size was a limitation of this study.Conclusions:Aboriginal people in Canada have a disproportionately large burden of ESKD, and PD could provide an alternative to in-center hemodialysis for those living in rural areas. Our study identified anxiety and lack of money as barriers to PD significantly associated with Aboriginal status. When choosing dialysis modality, shared decision making between physicians and patient is of key importance to weigh all potential benefits and risks and emphasize the Aboriginal patient’s values and preferences. These results can be used to guide future research and to help devise interventions targeting barriers to PD in Aboriginals.

Pre-dialysis renal clinic visits and patients' outcomes on peritoneal dialysis.

To investigate the effect of pre-dialysis renal care on peritoneal dialysis (PD) patients' outcomes in China. In this retrospective cohort study, patients who started PD during January 1, 2006, to December 31, 2014, were included. Patients' medical charts were reviewed to extract the information. To explore the effect of pre-dialysis renal care on patients' outcomes, patient were divided into two groups according to whether or not they had frequent renal clinic visits: Group A (with frequent visits) and Group B (without frequent visits). A total of 668 patients were included. Patients who admitted to emergency room before PD initiations were significantly higher in Group B than in Group A (42.7 vs. 33%, p=0.01). However, there was no significant difference in the proportion of patients requiring emergency hemodialysis prior to PD commencement (20.5 vs. 24.6%, p=0.21), acute heart failure (30.2 vs. 35.4%, p=0.16) and pulmonary infection (15.4 vs. 12.1%, p=0.23) between groups. Both the mortality and technical failure rate in Group A were significantly lower as compared to Group B (p=0.003 and p<0.01, respectively). Multivariable Cox regression analysis showed frequent pre-dialysis renal clinic visits were associated with both lower mortality rate (HR 0.62, 95% CI 0.46-0.85, p=0.003) and technical failure on PD (HR 0.58, 95% CI 0.36-0.92, p=0.022). Pre-dialysis frequent clinic visits were associated with better PD outcomes. Pre-dialysis renal clinic management was suboptimal in the present cohort. More organized system to ensure people with established chronic kidney disease are well managed is necessary in China.

Advance care planning for 600 Chinese patients with end-stage renal disease

Background/purposeThere is increasing recognition of the need to integrate advance care planning (ACP) into end-stage renal disease (ESRD) care with attention to medical, ethical, psychosocial, and spiritual issues but publications comparing patients who chose renal replacement therapy (RRT) and renal palliative care (RPC) is scarce. We here share our experience on ACP for ESRD patients in a center with renal replacement and palliative programs in place. MethodsFrom June 2006 to December 2011, ESRD patients were empowered to make an informed choice of future medical care in a structured ACP that was emphasized to be an ongoing process. Patients who opted for RRT and RPC would be followed up at the predialysis clinic and the one-stop multidisciplinary RPC clinic, respectively. This was a single-center study in a secondary care hospital. A total of 600 patients (265 RRT, 335 RPC) were enrolled and followed up over a median of 782 days. ResultsThe majority of patients and relatives declined dialysis because of perceived physical burden. Only 1.6% of palliative care patients changed their decision and commenced dialysis. Baseline characteristics differed between patients who chose RRT or RPC. Survival declined according to the modified Charlson Comorbidity Index scores. Older age, mental incompetence, hyperlipidemia, high modified Charlson Comorbidity Index, low estimated glomerular filtration rate, and low albumin were important independent predictors of poor survival. Factors affecting the ACP decision were discussed in the Chinese culture context. ConclusionA structured ACP could empower the patient to make an informed decision on the management of ESRD. 背景於未期腎病患者的照顧中加入關注身心社靈和倫理問題的預設照顧計劃(ACP)受到日益重視，但有關比較接受腎替代療法和接受腎臟紓緩治療文獻討論為數不多。作為同時提供腎透析服務以及腎臟紓緩治療的部門，本文旨在分享我們為未期腎病者討論預計照顧計劃的經驗。 方法自二零零六年六月至二零一零五月間，透過有組織的預設照顧計劃討論，未期腎病患者會被鼓勵就未來的治療計劃作出知情選擇。選擇腎透析和腎臟紓緩治療的病人會分別於透析預備門診和一站式跨科際腎臟紓緩治療門診去覆診。本研究於一家二級醫院進行。總共有六百病人參與此研究，當中265名接受腎透析，335名接受腎臟紓緩治療，其中位跟進日數為782日。 結果大部份病人和家屬之所以拒絕腎透析是由於預計的身體負累，只有百分之一點六接受腎臟紓緩治療會改變主義而接受腎透析。選擇腎透析和腎臟紓緩治療的病人在基本的身體狀況有明顯分別。生存率亦隨著修改版查爾森共病量表的分數而下降。年長、精神自主能力缺欠、高血脂、修改版查爾森共病量表分數高、腎小球濾過率低、白蛋白低均屬重要暨獨立的因素以預計較差的生存率。本文亦會探討在中國文化處境下影響預設照顧計劃討論的因素。 結論有組織的預設照顧計劃討論能幫助病人在未期腎病的醫療方向作出知情的選擇。

CKD in elderly patients managed without dialysis: survival, symptoms, and quality of life.

Survival, symptom burden, and quality of life (QOL) are uncertain for elderly patients with advanced CKD managed without dialysis. We examined these outcomes in patients managed with renal supportive care without dialysis (RSC-NFD) and those planned for or commencing dialysis. In this prospective observational study, symptoms were measured using the Memorial Symptom Assessment Scale and the Palliative care Outcomes Scale - Symptoms (renal) inventory and QOL was measured using the Short Form-36 survey. This study comprised 273 predialysis patients who had usual nephrology care and 122 nondialysis pathway patients who also attended a renal supportive care clinic adding the skills of a palliative medicine team. A further 72 patients commenced dialysis during this period without attending either clinic. Nondialysis patients were older than the predialysis group (82 versus 67 years; P<0.001) but had similar eGFR at the first clinic visit (16 ml/min per 1.73 m(2); P=0.92). Of the predialysis patients, 92 (34%) commenced dialysis. Compared with the RSC-NFD group, the death rate was lower in the predialysis group who did not require dialysis (hazard ratio, 0.23; 95% confidence interval, 0.12 to 0.41] and in those requiring dialysis (0.30; 0.13 to 0.67) but not in dialysis patients who had not attended the predialysis clinic (0.60; 0.35 to 1.03). Median survival in RSC-NFD patients was 16 (interquartile range, 9, 37) months and 32% survived >12 months after eGFR fell below 10 ml/min per 1.73 m(2). For the whole group, age, serum albumin, and eGFR <15 ml/min per 1.73 m(2) were associated with poorer survival. Of the nondialysis patients, 57% had stable or improved symptoms over 12 months and 58% had stable or improved QOL. Elderly patients who choose not to have dialysis as part of shared decision making survive a median of 16 months and about one-third survive 12 months past a time when dialysis might have otherwise been indicated. Utilizing the skills of palliative medicine helps provide reasonable symptom control and QOL without dialysis.

Percepción de la información recibida por el paciente en un centro de hemodiálisis

Information is a key factor to improve the physical and psychological situation of the patient. In the Lozano Blesa Dialysis Unit, in Zaragoza, the level of knowledge of the patients was evaluated before joining the haemodialysis (HD) programme. The strengths and weaknesses of the Unit were identified, and a plan of action was determined to rectify the deficiencies detected.A total of 36 of the 69 patients were selected. A descriptive, cross-sectional study, using qualitative questionnaire. Questions were related to the quality of the information, concepts of HD, diet, home treatment and medication, vascular access and its maintenance, different dialysis techniques, and the dialysis centre. The results obtained were the basis for writing a guidance manual for the patient, to justify other interventions, and to promote the chronic kidney diseas (CKD) pre-dialysis clinic.

A High Prevalence of Abnormal Nutrition Parameters Found in Predialysis End-Stage Kidney Disease: Is It a Result of Uremia or Poor Eating Habits?

To describe the baseline nutritional characteristics of a cohort of end-stage kidney disease (ESKD) patients attending a pre-dialysis clinic. Outpatient clinic of a metropolitan tertiary teaching hospital in Sydney, Australia. All ESKD patients attending the multidisciplinary pre-dialysis assessment clinic between April 2002 and March2008. Retrospective analysis of data extracted from the routine initial nutrition assessment records. These included anthropometric and biochemical measures, Subjective Global Assessment, appetite score, presence of symptoms, dietary energy, protein, and other macro- and micronutrient intakes. Of the 210 patients assessed, 60.5% were male; mean age was 65.7±13.6years with a mean glomerular filtration rate of 17.3±6.5mL/min/1.73m(2); 17.1% and 62.4% were underweight (body mass index <23kg/m(2)) and overweight or obese (BMI ≥26kg/m(2)), respectively; 40.5% were rated as malnourished (Subjective Global Assessment scores B and C) with 19.0% overweight/obese and malnourished. Energy and protein intakes correlated positively with glomerular filtration rate, with r=0.17, P = .01, and r=0.29, P<.0001 respectively. Mean energy and protein intakes were 23.7±6.7kcal/kg IBW/day and 1.18±0.42g/kg IBW/day, with 62.6% and 13.1% not meeting the recommended intake, respectively. The positive predictive values (95%CI) of self-rated appetite score for energy and protein were 0.41 (0.36-0.45) and 0.92 (0.88-0.95), respectively, indicating subjective rating of a good appetite was associated with adequate protein but not energy intake. Fifty-one percent of the patients experienced the symptoms, whereas 17.5% of the patients self-imposed a dietary regimen inappropriately due to beliefs on dietary needs in ESKD. Suboptimal nutrient intakes were observed, including vitamin B2 (41.2%), vitamin E (61.8%), folate (67.6.2%), vitamin D (100.0%), and zinc (64.2%). Patients presented to the pre-dialysis assessment clinic with abnormal nutrition parameters associated with decreased renal function, symptoms burden, and poor dietary intake. This clinic may provide an opportunity to optimize the nutritional status of ESKD patients in the pre-dialysis period.

Effect of aliskiren in chronic kidney disease patients with refractory hypertension undergoing hemodialysis: a randomized controlled multicenter study

Applying a direct renin inhibitor (DRI) to advanced stage chronic kidney disease (CKD) patients is a matter of controversy. The purpose of this study was to evaluate the effect of the DRI, aliskiren, in patients with therapy-resistant hypertension undergoing hemodialysis (HD). The study was a prospective, randomized multicenter trial exploring the antihypertensive effect of aliskiren in comparison with amlodipine, a calcium channel blocker, in patients undergoing HD. A total of 83 participants whose blood pressure (BP) had previously been treated with more than one antihypertensive agent and not having achieved the BP goal of <140/90 mmHg were randomly assigned to either aliskiren 150 mg or amlodipine 5 mg as an add-on therapy. A significant decrease in pre-dialysis clinic BP and home BP was found only in the amlodipine group and not in the aliskiren group. In contrast, there was a significant decrease in atrial natriuretic peptide (ANP) in the aliskiren group but not in the amlodipine group. N-terminal pro-B-type natriuretic hormone remained unchanged in both groups. Aliskiren significantly reduced angiotensin I and II, plasma renin activity, and increased plasma renin content. However, such changes were not observed in the amlodipine group. Amlodipine, not aliskiren, effectively reduces BP in CKD patients with refractory hypertension undergoing HD. Aliskiren suppresses the renin-angiotensin system and reduces ANP. Whether the DRI is beneficial in improving cardiovascular events in patients undergoing HD remains to be elucidated in future studies.

Comparison of survival analysis and palliative care involvement in patients aged over 70 years choosing conservative management or renal replacement therapy in advanced chronic kidney disease

Background: There are limited data on the outcomes of elderly patients with chronic kidney disease undergoing renal replacement therapy or conservative management. Aims: We aimed to compare survival, hospital admissions and palliative care access of patients aged over 70 years with chronic kidney disease stage 5 according to whether they chose renal replacement therapy or conservative management. Design: Retrospective observational study. Setting/participants: Patients aged over 70 years attending pre-dialysis clinic. Results: In total, 172 patients chose conservative management and 269 chose renal replacement therapy. The renal replacement therapy group survived for longer when survival was taken from the time estimated glomerular filtration rate <20 mL/min (p < 0.0001), <15 mL/min (p < 0.0001) and <12 mL/min (p = 0.002). When factors influencing survival were stratified for both groups independently, renal replacement therapy failed to show a survival advantage over conservative management, in patients older than 80 years or with a World Health Organization performance score of 3 or more. There was also a significant reduction in the effect of renal replacement therapy on survival in patients with high Charlson’s Comorbidity Index scores. The relative risk of an acute hospital admission (renal replacement therapy vs conservative management) was 1.6 (p < 0.05; 95% confidence interval = 1.14–2.13). A total of 47% of conservative management patients died in hospital, compared to 69% undergoing renal replacement therapy (Renal Registry data). Seventy-six percent of the conservative management group accessed community palliative care services compared to 0% of renal replacement therapy patients. Conclusions: For patients aged over 80 years, with a poor performance status or high co-morbidity scores, the survival advantage of renal replacement therapy over conservative management was lost at all levels of disease severity. Those accessing a conservative management pathway had greater access to palliative care services and were less likely to be admitted to or die in hospital.

How Accurately Do Nephrologists Predict the Need for Dialysis within One Year?

Background/Aims: Knowing when patients with chronic kidney disease will need dialysis can improve patient counselling and timing of vascular access. We aimed to assess the accuracy of clinician judgement in predicting the need for dialysis within 12 months. Methods: We asked the nephrologists in a dedicated pre-dialysis clinic to predict the time until initiation of dialysis for patients. We compared predicted with actual time to dialysis and the accuracy of predictions made by different grades of clinician. Multivariate logistic regression compared clinical parameters that correlated with predicted and actual time to dialysis. Results: One hundred and eighty-four patients were included. The sensitivity of clinician judgement as a predictor of dialysis within 12 months was 95% and the specificity was 62%. Consultants were correct in 71% of cases and trainees in 68% of cases. Estimated glomerular filtration rate (eGFR) was the only independent correlate of predicted time to dialysis [odds ratio (OR) = 1.6 per 1 ml/min/1.73 m² reduction, p < 0.001]. eGFR was also associated with actual time to dialysis (OR = 1.6 per 1 ml/min/1.73 m², p < 0.001) along with age (OR = 0.94 per year increase, p = 0.005) and itch (OR = 3.7, p = 0.048). Conclusion: Clinical judgement is sensitive but not specific in predicting the need for dialysis. Educating the clinicians may improve the specificity of judgement and improve the accuracy of prognostic information given to patients.

Is lack of suitable housing a barrier to home-based dialysis therapy for patients with end-stage renal disease? A cohort study

ObjectiveTo determine whether inadequate housing is the main barrier to the provision of home dialysis treatment.DesignProspective observational study.ParticipantsAll patients attending a predialysis clinic between 2006 and 2009 deemed medically suitable...

Optimizing AVF creation prior to dialysis start: the role of predialysis renal replacement therapy choices

In British Columbia, multidisciplinary predialysis clinics encourage patients to consider independent modalities of renal replacement therapy (RRT) such as peritoneal dialysis (PD) 'first'. Despite up to 50% of patients choosing PD, PD incidence rates are ~30%. We explored the relationship between predialysis RRT choice and arteriovenous fistula (AVF) creation prior to hemodialysis (HD) start with particular focus on the group of patients who despite PD choice actually commence HD, and thus may contribute to 'suboptimal' HD starts without AVF creation. We conducted a retrospective cohort study of all patients starting dialysis between 31 December, 2006 and 31 December 2008 in the province of British Columbia. Inclusion criteria were >3 months predialysis nephrology follow-up, at least one predialysis RRT education session and maintenance on dialysis for a minimum of 3 months (to ensure chronic dialysis). Patients with any prior history of RRT were excluded. There were 508 patients included in the study: 127 (25%) patients chose HD, 114 (22%) PD, 13 (3%) pre-emptive transplant, 5 (1%) conservative management and 249 (49%) had no documented modality decision. Of those who chose HD, 94% commenced HD. For those who chose PD, 64% commenced PD and 36% HD. In the undecided group, 68% started HD and 32% PD. For those patients who chose PD predialysis, the presence of cardiovascular disease [odds ratio (OR) 2.36, 95% confidence interval (CI) 1.02-5.43] and lower serum albumin levels (OR 0.92, 95% CI 0.86-0.98) were associated with failure to commence PD. Predialysis AVF creation rates were 79% of those who chose and started HD, 39% of those who chose PD but started HD and 50% of those in the undecided group who commenced HD. AVF creation rates prior to HD start were lower in those patients with no documented dialysis modality choice and in those who failed to commence PD. Cardiovascular disease and lower serum albumin levels were associated with failure to start PD. Further work to ensure the efficacy of RRT modality choice pathway and to better predict those patients who will fail to commence PD is necessary, so that dialysis start can be 'optimized' with AVF creation in high-risk groups.

Bone mineral density by DXA and HR pQCT can discriminate fracture status in men and women with stages 3 to 5 chronic kidney disease

Fractures are common in chronic kidney disease (CKD). We determined if bone mineral density testing by dual energy X-ray absorptiometry (DXA) and high resolution peripheral quantitative computed tomography (HR pQCT) could discriminate fracture status in CKD patients. Both tests were able to discriminate fracture status. Further, the addition of HR pQCT measurements to DXA measurements did not improve fracture discrimination. The optimal method to identify individuals with CKD at high fracture risk is unknown. We determined if bone mineral density (BMD) by DXA and HR pQCT could discriminate fracture status in 211 adult men and women with stages 3 to 5 CKD, attending predialysis clinics in Toronto Canada, using logistic regression. Results are expressed as the odds ratio (OR) of fracture (prevalent vertebral and/or low trauma since age 40 years) per standard deviation decrease in the predictor adjusted for age, weight, sex, and CKD stage. We constructed receiver operating characteristic curves to examine the discriminative ability of BMD measures for fracture. Most participants were Caucasian men with a mean age of 63.3 ± 15.5 years. There were 77 fractures in 74 participants. Decreases in BMD were associated with increased fracture risk: OR = 1.56 (95% confidence interval (CI), 1.41 to 1.71) for BMD by DXA at the ultradistal radius, and OR = 1.24 (95% CI, 1.12 to 1.36) for cortical area by HR pQCT. Further, while both tests were able to discriminate fracture status, the addition of HR pQCT measures to BMD by DXA did not improve fracture discrimination ability. Among CKD patients not yet requiring renal replacement therapy, BMD by DXA is able to discriminate fracture status.

Modifiable Risk Factors for Early Mortality on Hemodialysis

Data of incident hemodialysis patients from 2001 to 2007 were abstracted from The Renal Disease Registry (TRDR) from central Ontario, Canada and followed until December 2008 to determine 90-day mortality rates for incident hemodialysis patients. Modifiable risk factors of early mortality were determined by a Cox model. In total, 876 of 4807 incident patients died during their first year on dialysis; 304 (34.7%) deaths occurred within the first 90 days of dialysis initiation. The majority of deaths were attributed to a cardiovascular event or infection and more likely occurred in older patients and those with cardiovascular co-morbidities. Of potentially modifiable risk factors, low body mass index (<18.5), a surrogate for malnutrition, was a strong predictor of early mortality [adjusted hazard ratio (HR) 4.22 (CI: 3.12–5.17)]. Also, central venous catheter use was associated with a 2.40 fold increase risk of death (CI: 1.4–3.90). Patients who attended a multidisciplinary pre-dialysis clinic were less likely to die (HR: 0.60, CI: 0.47–0.78). The first 90 days after initiation of dialysis is a period of especially high risk of death. We have identified potentially modifiable risk factors in vascular access type, pre-dialysis care and nutritional status.

A new approach to psychological support in the renal setting

There is wide scope for psychologists to contribute to secondary prevention in non-reversible medical conditions such as end-stage renal disease (ESRD): reducing further avoidable health deterioration through enhancing patients' adjustment and adherence to medical advice and treatment. Two phases in patients' journeys are particularly significant, their transition from the pre-dialysis clinic to dialysis-based renal replacement therapy (RRT) and their assessment for transplantation. We devised structured interviews with patients in these stages aimed at identifying and addressing illness acceptance issues and barriers to future adherence, delivered through clinics run in parallel with nursing and medical colleagues. They have broadened our understanding of both staff and patient concerns about transition to RRT or listing for transplants and provided a context for both brief preventive and further follow-up work. Key to enhancing psychological preparedness has been exploring the meaning ascribed to the forthcoming change and patients' personal health beliefs, in the context of their broader life situation, values and goals.

Why did I start dialysis? A qualitative study on views and expectations from an elderly cohort of patients with end-stage renal failure starting haemodialysis in the United Kingdom

It is now common for elderly patients with end-stage kidney disease to be offered treatment by dialysis. However, what these patients expect from dialysis is not known. Therefore, the purpose of this study was to elucidate the expectations of elderly patients starting dialysis and to investigate whether their views change after 6 months on this treatment. This was a prospective observational qualitative study of patients commencing haemodialysis in our centre from 2006 to 2007. Data were collected by interview and review of case notes at the time of starting dialysis and after 6 months of treatment. Patients were asked about their expectations from dialysis, symptoms, and views on advance care planning. Data were collected from 22 patients (mean age 69.1 years) within a month from starting dialysis. Seventy per cent of these patients had attended a pre-dialysis clinic for at least 4 months previously; despite this, many of the patients complained about having had little choice in starting dialysis and seemed uncertain about what dialysis would involve. Even so, over 90% of those interviewed were optimistic about dialysis, had high expectations from treatment and were not keen to discuss advance care planning at first interview. Sixteen patients were re-interviewed at 6 months (four patients had died meanwhile and two had been transferred to other centres). After 6 months, there was a change in patients' attitude, with only 45% of them still finding dialysis acceptable and more patients now keen to discuss advance care planning. Symptom burden was higher at 6 months than at initiation of dialysis treatment. Most elderly patients have unrealistic expectations from dialysis at the start of treatment. There is a need for more specific counselling of these patients to ensure that they make informed decisions about treatment modality and have realistic expectations if they chose to receive RRT.

Impact of collaborative and multidisciplinary care on management of hypertension in chronic kidney disease outpatients

Objective In patients with chronic kidney disease (CKD), blood-pressure (BP) control is crucial. ProFiL, a training and communication-network programme, is designed to optimize community pharmacists' management of drug-related problems among CKD outpatients. This study evaluates the impact of ProFiL on BP control and management of hypertension treatment. Methods In a 6-month cluster randomized trial, community pharmacies of CKD outpatients (creatinine clearance, <60 ml/min) attending a predialysis clinic in Quebec, Canada, were randomly assigned to ProFiL (intervention) or usual care (UC). ProFiL community pharmacists attended a training workshop, received patient information and had access to a hospital-pharmacist consultation service. UC pharmacists provided routine care. Key findings Eighty-nine patients (ProFiL, 48; UC, 41) participated. At 6 months, adjusted mean systolic/diastolic BP changes, taking within-cluster correlation into account, were −6.9/−0.4 mmHg in ProFiL patients compared with +4.7/+2.2 mmHg in UC (between-groups differences, P value = 0.021/0.348). Some 41 hypertension drug-related problems were identified. Community pharmacists wrote 25 recommendations (ProFiL, 24; UC, 1; P value = 0.007), 12 of which, all by ProFiL pharmacists, dealt with hypertension (P value = 0.009 compared with UC). Patients with written hypertension recommendations had a greater decrease in mean systolic BP (−11.6 mmHg; P value = 0.035), and BP was controlled in a higher proportion of them (relative risk, 2.14; P value = 0.011). Conclusion ProFiL, a collaborative and multidisciplinary care programme, may help pharmacists to intervene more often to detect and manage hypertension drug-related problems and optimize BP control in CKD outpatients.

Dedication of a nurse to educating suboptimal haemodialysis starts improved transition to independent modalities of renal replacement therapy

Haemodialysis (HD) initiation is unplanned in up to 50% of patients, mainly due to late diagnosis and/or late nephrology referral. In these patients, time does not permit the multidisciplinary predialysis care that is associated with increased independent renal replacement therapy (RRT) modality choice and better access to kidney transplantation. We established a Renal Triage Nurse (RTN) position to educate suboptimal HD starts and to facilitate transition to independent modalities of RRT. Adult patients starting HD from 1 January 2005 to 31 December 2008 with < 180 days nephrology follow-up and surviving at least 180 days were included (suboptimal HD starts). The RTN educated suboptimal HD starts beginning in December 2006. Patients initiating RRT via the multidisciplinary predialysis clinic (MPC) were included for comparison. Multivariable logistic regression was used to determine the association between being seen by the RTN and achieving independent modalities of RRT. There were 176 patients: 78 suboptimal HD starts (38 of these were educated by the RTN) and 98 patients initiated RRT after a minimum 180-day follow-up at the MPC. Of the RTN patients, 27.8% switched to independent RRT modalities (peritoneal dialysis n = 7, home haemodialysis n = 1, transplant n = 2). RTN patients were more likely to live alone (33.3% versus 10.8%, P = 0.02) and to have cerebrovascular disease (25.0% versus 7.1%, P = 0.03); however, adjusting for these variables, suboptimal HD starts seen by the RTN were more likely to transition to independent RRT (OR 3.75, 95% CI 1.08-13.05) than those not seen. The proportion starting on an independent modality via the MPC was 39.8%. The RTN achieved a rate of independent RRT not statistically different to that observed in patients starting RRT via the MPC (OR 0.74, 95% CI 0.19-2.94 in multivariable analysis). Addition of the RTN to the HD care team facilitated transition to independent modalities of RRT in suboptimal HD starts. This standardized approach to the care of such patients should be considered in HD units where suboptimal HD starts are common.

The history of peritoneal dialysis: Early years at Toronto Western Hospital

The history of peritoneal dialysis: Early years at Toronto Western Hospital