Renal Care Research Articles

Issue Information: Journal of Renal Care 4/2024

Issue Information: Journal of Renal Care 4/2024

Nephrology Services in Telangana

Telangana has well-developed state-of-art nephrology services. The state boasts of a unique hub-and-spoke model of hemodialysis and an active deceased donor program called “Jeevandan.” The state was one of the first to initiate the public-private model of kidney care under the cashless “Aarogyasri” scheme. Digital health has made easy access to lab investigations for the doctors as well as patients. Telemonitoring of remote dialysis units is another policy undertaken by the Telangana government that has immensely improved the dialysis quality. This review describes the various nephrology services available, current state of renal care services in the state.

Preparing the ground for bespoke nursing training in advanced renal cell carcinoma care (RCC4Nurses): An international prospective study

ObjectivesNurses require specialist knowledge and skills to effectively support an increasing population of people affected by advanced renal cell cancer (aRCC). RCC4Nurses was a three-phase project that aimed to develop bespoke training in aRCC for nurses in Europe. Phase 1 examined pre-existing educational programs in kidney cancer, then developed a curriculum of core education topics in aRCC care to suit generalist and specialist nurses’ education needs. MethodsPhase 1 employed a prospective design that involved two parts. Part 1 was a scoping review of educational programs developed for multidisciplinary health professionals in kidney cancer/RCC. Findings of Part 1 formed the basis for Part 2, which was a three-round Delphi study that involved experts by personal experience or profession in aRCC, who rated the importance of a range of education topics and education methods for inclusion in the developing RCC4Nurses. ResultsThe scoping review identified eight education programs via two published reports and six online resources. Existing programs had limitations in accessibility, recency and target professional groups; none of them was developed specifically for nurses. Program content was primarily focused on diagnostic, treatment and management procedures in kidney cancer. Fourteen educational topics were derived from the review and evaluated during Round 1 of the Delphi by 47 experts. By Round 3, 17 topics had iteratively reached consensus for inclusion within RCC4Nurses. Experts showed preference to problem-solving and clinical-scenario learning methods, but not reflective practice learning. ConclusionsGiven the dearth of up-to-date, evidence-based training for nurses in aRCC, we have prepared the ground to develop a bespoke training course in this area of practice. Implications for Nursing PracticeThe RCC4Nurses project will offer accessible, state-of-the-art education to registered nurses in Europe to help enhance nursing competency in aRCC and enhance the standard of care provided to people affected by aRCC.

Nursing Care and Postgraduate Education of Nephrology and Dialysis Nurses in Italy.

Introduction. Patients with chronic kidney disease undergoing renal replacement therapy have complex care needs. To address this, nephrology and dialysis nurses must possess expertise in advanced specialist and disciplinary skills. The aim of this review is to analyze post-graduate academic training pathways and clinical-care training in the field of nephrology and dialysis nursing in the Italian context. Methodology. A narrative review of the literature was conducted in May 2024, using databases such as CINAHL and Medline-PubMed, with a selection criterion limited to primary and secondary studies published in Italian and English. To supplement the search, particularly within the Italian context, grey literature sources were consulted. Results. Post-graduate nephrology nursing education in Italy is mainly offered through First-Level Masters, as well as Second Level Masters and specialization courses, which are provided at various academic institutions. Analysis of the educational programs revealed the presence of common "core" teachings across all pathways, covering renal disease pathophysiology, hemodialysis, peritoneal dialysis, and dialysis nursing care, alongside significant heterogeneity in other proposed teachings. Clinical-care training emerged as a fundamental aspect in both post-graduate education, professional integration for newcomers, and continuous professional development. Conclusions. The growing healthcare need for specialist skills suggests the necessity of integrating field-based training with standardized post-graduate academic pathways, possibly in collaboration with relevant Nursing Scientific Societies. This synergy would not only promote the enhancement of nursing competencies but also ensure a high quality of care delivery.

HED-Start: A Brief Positive Psychology Cluster-Randomized Controlled Trial to Improve Psychological Adjustment in Patients New on Hemodialysis.

Initiation onto hemodialysis marks a critical transition with intense psychosocial demands. Interventions using cognitive-behavioral therapy to improve distress have been variably effective but require trained staff and are typically delivered only to those who screen positive for clinically significant distress. Interventions guided by positive psychology are lacking. To investigate the effectiveness of a brief positive-skills RCT in improving psychological adjustment in new hemodialysis patients. Using a parallel (2:1) design, blinded cluster-randomized controlled trial (cRCT) design, incident patients (<6 months at NKF dialysis centers) undergoing hemodialysis were randomized to intervention or usual care (UC). HED-Start intervention comprised four group sessions delivered by healthcare staff on positive emotions, acceptance, and life-orientated goal setting. Measures were taken at baseline (pre-randomization) and at 12 weeks: distress/mood (HADS; SPANE); quality of life (KDQOL-SF, WHOQOL-BREF); benefit-finding (BFS, BIPQ); life-oriented skills (HEIQ, CD-RISC-2); self-efficacy (CD-SES). A total of 147 participants enrolled in the trial (response rate, 51.0%; retention [assessment], 90.5%). Study arms were comparable on all baseline and outcome variables except for age, diabetic nephropathy, and hypertensive nephrosclerosis which were subsequently controlled for. Repeated measures ANCOVAs (intention to treat) were used. HED-Start yielded significant reductions over time in depression, and increased quality of life, self-efficacy, benefit finding, and skills relative to UC (moderate effect sizes). Rates of clinically significant depression significantly decreased in HED-Start (p < .001) and increased in UC (p = .002). The significant positive effects of HED-Start, a low-intensity and cost intervention, on several adjustment indices, suggest that programs focusing on positive life skills can value add to existing renal care services.

Perspectives of Chinese nephrology nurses on discussing sexual dysfunction with patients receiving haemodialysis: A qualitative study.

The study underscores the crucial yet often neglected issue of sexual dysfunction in haemodialysis patients. Despite nephrology nurses'close relationships with patients, there is a significant communication gap on this topic. In China, limited research highlights the need for further study. To describe the perspectives of Chinese nephrology nurses on discussing sexual dysfunction with patients receiving haemodialysis. A qualitative descriptive study. Ten Chinese nephrology nurses from a tertiary public hospital in Guizhou province, China. Semistructured interviews were conducted using an interview guide. Qualitative content analysis approach was utilised in analysis. There were five themes described: (1) lack of training in sexual education, as nephrology nurses described never being trained to manage patients' sexual health issues; (2) discomfort when discussing sexual topics, Chinese nephrology nurses found the topic of sexual dysfunction embarrassing and avoided discussing it; (3) sexual dysfunction viewed as a nonurgent topic, nephrology nurses prioritise physical health to aid patient survival; (4) belief in physicians as ultimate care advisors, nephrology nurses believed that doctors should handle discussions on sexually related topics; and (5) lack of a suitable environment for discussing sexual dysfunction, nephrology nurses viewed sex as a private matter, inappropriate for discussion in a public unit. The study identifies barriers to discussing sexual dysfunction in healthcare, including provider knowledge deficits, discomfort and lack of supportive environments. It recommends specialised training and conducive settings to improve communication in renal care. Future research should evaluate the effectiveness of these interventions.

Exemplary Practices in Kidney Care: Sharing the Experience of " Disease Care Certification"

&lt;p&gt;2019年8月，本院腎臟團隊首次參與醫策會「腎臟病照護品質認證」，在委員查核下通過認證。近三年來，本院透過外部審核和交流，不斷增強自身實力，凝聚成員共識，進行腎臟照護標準化。以「病人為中心」執行醫療服務，促進跨領域合作，拓展研究領域。本團隊亦致力於品質改進和減少異常發生，建立新透析中心積極應對COVID-19及其他嶄新挑戰。在數位轉型過程中，本院更引進電子病歷智慧輔助系統，利用One System整合平台提升照護效率。同時，針對末期腎病(Pre-ESRD)5期病人，提前啟動醫病共享決策(SDM)，成立「愛腎家族」群組，強調醫療團隊成員和病人之間的合作。在高品質連續性照護基礎上，為急性腎損傷、慢性腎臟病、和需要透析的病人建立全面性的照護機制。&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;&lt;p&gt;In August 2019, our hospital&amp;rsquo;s renal team participated for the first time in the Disease-Specific Care Kidney Disease certification program and achieved certification from the Joint Commission of Taiwan. Over the preceding three years, this team has consistently strengthened itself through external audits and exchanges, fostering consensus among its members and achieving standardization in renal care. Focusing on patient-centered care, the team&amp;rsquo;s main goals are to enhance core medical services, promote cross-disciplinary integration, and expand research areas. Our team is also dedicated to improving quality of care and mitigate anomalies. Furthermore, a new dialysis center was established to proactively respond to COVID-19 and other emerging challenges. During the digital transformation process, our hospital introduced an intelligent electronic medical record assistance system and utilized the One System integration platform to enhance care efficiency. For patients with stage 5 pre-end-stage renal disease, we proposed early shared decision-making standards, established a &amp;ldquo;Love Kidney Family&amp;rdquo; group, and emphasized the importance of collaboration between healthcare providers and patients. These initiatives were aimed at developing a foundation for offering comprehensive, high-quality care for patients with acute kidney injury, chronic kidney disease, and those requiring dialysis.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

221.5: Advancing renal transplant patient care: Unveiling eplet mismatch thresholds for precise risk assessment and prognosis.

221.5: Advancing renal transplant patient care: Unveiling eplet mismatch thresholds for precise risk assessment and prognosis.

WHEN PHYSICIAN SUPPLY DOES NOT MEET PATIENT DEMAND: A LOOMING EPIDEMIC IN VASCULAR AND RENAL CARE FOR A COMMUNITY WITH THE HIGHEST INCIDENCE OF END-STAGE RENAL DISEASE IN THE UNITED STATES.

South Texas and the Rio Grande Valley (RGV) are medically underserved-communities near the Texas-Mexico border with the highest incidence of end-stage renal disease (ESRD) in the nation, and a shortage of available full-time equivalent (FTE) specialty-physicians. Data on the incidence/prevalence of ESRD and workforce projections on vascular-surgeons and nephrologists were collected from the United States Renal Data System and Texas Department of State Health Services. We then merged data from both datasets to identify population-specific healthcare-trends. Texas had the highest rates of ESRD from 2016 to 2020, with its border regions leading the state. By 2032, vascular-surgery and nephrology are projected to have the 1st and 4th worst physician-shortages in the state respectively, with the percentage of these FTE specialty-physicians available to meet the need of the RGV ranging from 42.3 to 58.4​%. The RGV is experiencing increased rates of ESRD, while having a paradoxical-decline in specialty-physicians available to provide adequate care.

The burden of hyperkalaemia on hospital healthcare resources

Hyperkalaemia is associated with prolonged hospital admission and worse mortality. Hyperkalaemia may also necessitate clinical consults, therapies for hyperkalaemia and high-dependency bed utilisation. We evaluated the ‘hidden’ human and organisational resource utilisation for hyperkalaemia in hospitalised patients. This was a single-centre, observational cohort study (Jan 2017–Dec 2020) at a tertiary-care hospital. The CogStack system (data processing and analytics platform) was used to search unstructured and structured data from individual patient records. Association between potassium and death was modelled using cubic spline regression, adjusted for age, sex, and comorbidities. Cox proportional hazards estimated the hazard of death compared with normokalaemia (3.5–5.0 mmol/l). 129,172 patients had potassium measurements in the emergency department. Incidence of hyperkalaemia was 85.7 per 1000. There were 49,011 emergency admissions. Potassium > 6.5 mmol/L had 3.9-fold worse in-hospital mortality than normokalaemia. Chronic kidney disease was present in 21% with potassium 5–5.5 mmol/L and 54% with potassium > 6.5 mmol/L. For diabetes, it was 20% and 32%, respectively. Of those with potassium > 6.5 mmol/L, 29% had nephrology review, and 13% critical care review; in this group 22% transferred to renal wards and 8% to the critical care unit. Dialysis was used in 39% of those with peak potassium > 6.5 mmol/L. Admission hyperkalaemia and hypokalaemia were independently associated with reduced likelihood of hospital discharge. Hyperkalaemia is associated with greater in-hospital mortality and reduced likelihood of hospital discharge. It necessitated significant utilisation of nephrology and critical care consultations and greater likelihood of patient transfer to renal and critical care.

Towards equitable renal care: Strategies for enhancing kidney transplantation in Africa

Chronic kidney disease (CKD) is defined as the presence of kidney damage persisting for 3 months or more. Kidney transplantation stands as a vital intervention for individuals grappling with end-stage renal disease (ESRD) in Africa, offering the promise of extended life and improved quality of life. However, numerous challenges hinder its widespread implementation across the continent. This paper explored kidney transplantation in Africa, aiming to illuminate key strategies for bridging gaps and building pathways to enhanced renal care. There is a disproportionate burden of CKD on the region's population. Therefore, there is a critical need for early diagnosis and intervention. This paper outlines comprehensive strategies for improving kidney transplantation in Africa. Results indicate that financial support systems, infrastructure enhancement, public awareness campaigns, and legal frameworks are essential for addressing renal care barriers. Active measures such as government subsidy programs, international funding collaboration, and engagement with community leaders are highlighted as effective approaches. Drawing from global standards and best practices, the paper shows the importance of tailored approaches that address Africa's unique socio-economic and healthcare landscape. By leveraging collaborative efforts, regulatory frameworks, and public engagement, African nations can overcome barriers to kidney transplantation and pave the way for equitable access to life-saving treatment.

A Qualitative Study Supporting Optimal Nutrition in Advanced Liver Disease-Unlocking the Potential for Improvement.

Malnutrition rates in Advanced Liver Disease (ALD) are significantly higher than those in well-compensated liver disease. In addition to its physiological impact, malnutrition is detrimental for quality of life and social, emotional, and psychological well-being. Studies within oncology and renal supportive care have identified the influence of non-physiological factors on malnutrition risk. Integrating similar factors into malnutrition screening for ALD could improve identification of at-risk patients to optimize treatment planning. This qualitative study aimed to understand the holistic factors influencing nutritional status in the ALD population. Semi-structured interviews with 21 patients, carers, and clinicians explored the experiences of malnutrition in ALD. Thematic analysis revealed five key themes: (i) appropriateness of healthcare delivery; (ii) health- and food-related factors; (iii) high symptom burden, (iv) social support impacting well-being, and (v) physical and structural supports. Current screening methods do not adequately capture all potential drivers of malnutrition in the ALD population. Adopting a more supportive approach including both physiological and non-physiological factors in ALD malnutrition screening may promote more timely and comprehensive nutritional interventions that address the complex and holistic needs of patients living with ALD.

Corticomedullary Differentiation in Fetal Kidneys: A Necessary Evil?

AbstractRenal corticomedullary differentiation (CMD) is a crucial indicator of fetal renal health and is detectable as early as 15 to 16 weeks of gestation. Abnormalities in CMD, such as accentuation or loss, may signal underlying renal diseases. CMD assessment via prenatal ultrasound evolves dynamically throughout gestation, reflecting changes in cortical echogenicity and cystic structures. While CMD alterations can indicate conditions like glomerulonephritis or obstructive uropathies, they also offer prognostic insights into future renal function. This case report highlights the importance of early detection and comprehensive evaluation of CMD for optimising prenatal renal care.

The utilization of renal dialysis: a comprehensive study in Saudi Arabia

BackgroundUnderstanding the trend of utilization of renal dialysis in Saudi Arabia (SA) is fundamental as it provides a general overview of renal care. The practice of renal dialysis assists in identifying challenges, opportunities, and potential areas for improvement in the provision of the services.ObjectivesThis research investigated the utilization of renal dialysis services in SA by exploring the number of renal dialysis centers, hemodialysis machines (HD), and peritoneodialysis patients.MethodsThe dataset for this study was derived from a collaboration between the General Authority of Statistics (GaStat) and the Ministry of Health (MoH), focusing on indicators for renal dialysis centers and patients across health sectors in 2021. Analysis was conducted using MS Excel 365 and IBM SPSS Version 29, incorporating multiple regression techniques. The health sector was treated as the dependent variable. At the same time, the number of hemodialysis (HD) machines and the counts of HD and peritoneal dialysis patients were considered independent variables.ResultsAround 275 renal dialysis centers, over 8000 HD machines, 20,440 HD patients, and 1,861 peritoneal patients were tallied from two resources. The findings revealed a negative relationship between the health sector and several renal dialysis centers and peritoneodialysis patients, as demonstrated by p < 0.05 in multiple regression analysis.ConclusionThe number of renal dialysis centers influences the availability of HD machines, affecting the number of HD and peritoneodialysis patients. Most national patients preferred MoH over other semi-governmental and private sectors, and vice versa for non-Saudis.

Protocol for a hybrid effectiveness-implementation clinical trial evaluating video-assisted electronic consent vs standard consent for patients initiating and continuing haemodialysis in Australia (eConsent HD)

IntroductionCommunicating complex information about haemodialysis (HD) and ensuring it is well understood remains a challenge for clinicians. Informed consent is a high-impact checkpoint in augmenting patients’ decision awareness and engagement...

Risk factors for converting traditional wards to temporary intensive care units during the COVID-19 pandemic: Insights from nurses' perspectives.

The surge in critically ill COVID-19 patients caused a shortage of intensive care unit (ICU) beds. Some hospitals temporarily transformed general wards into ICUs to meet this pressing health care demand. This study aims to evaluate and analyse the risk factors in temporary ICU from the perspective of nurses. By identifying these factors, the goal is to provide actionable insights and recommendations for effectively establishing and managing temporary ICUs in similar crisis scenarios in the future. The study was conducted in China within a public hospital. Specifically, it focused on examining 62 nurses working in a temporary ICU that was converted from an infectious disease ward. The research utilized the Hazard Vulnerability Analysis (HVA) scoring method to identify potential threats, evaluate their probability, estimate their impact on specific organizations or regions and calculate the relative risk associated with such occurrences. Staff demonstrated the highest risk percentage (32.74%), with Stuff (16.11%), Space (15.19%) and System (11.30%) following suit. The most critical risk factors included insufficient knowledge and decision-making competence in critical care (56.14%), lacking decision-making abilities and skills in renal replacement therapy care (55.37%), inadequate decision-making capacity and relevant skills in respiratory support care (50.64%), limited decision-making capability in circulatory support care (45.73%) and unfamiliarity with work procedures or systems (42.09%). Urgent implementation of tailored training and support for temporary ICU nurses is paramount. Addressing capability and skill-related issues among these nurses supersedes resource availability, infrastructure, equipment and system considerations. Essential interventions must target challenges encompassing nurses' inability to perform critical treatment techniques autonomously and ensure standardized care. These measures are designed to heighten patient safety and elevate care quality during emergencies. These findings offer a viable avenue to mitigate potential moral distress, anxiety and depression among nurses, particularly those transitioning from non-critical care backgrounds. These nurses swiftly assimilate into temporary ICUs, and the study's insights offer practical guidance to alleviate their specific challenges. The study on risk factors for converting traditional wards into temporary ICU during the COVID-19 pandemic, especially from the perspective of nurses, provides crucial insights into the challenges and requirements for effectively establishing and managing these emergency settings. The findings highlight several key areas of concern and opportunities for improvement directly related to clinical practice, particularly in situations where there is a rapid need to adapt to increased demands for critical care. By addressing the identified risk factors through enhanced training, support systems, resource management, process improvements and cultivating a culture of adaptability, not only can the quality of care in temporary ICUs be improved, but also can the health care system be better prepared for future emergencies. These actions will help mitigate the risks associated with such conversions, ultimately benefiting patient safety, staff well-being and the overall effectiveness of health care services in crises.

Frequency Determination of Central Line Associated Bloodstream Infection at a Renal Care Centre

Frequency Determination of Central Line Associated Bloodstream Infection at a Renal Care Centre

Barriers and facilitators to vascular access point-of-care ultrasound in haemodialysis: An international survey of haemodialysis clinicians.

Utilising point-of-care ultrasound for assessment and cannulation of vascular access in people receiving haemodialysis has shown positive clinical results. Nonetheless, there is variation in how renal health care professionals worldwide embrace this method, and there's a lack of research on the factors that promote or hinder its adoption. To explore regional differences, and barriers and facilitators, to the use of point-of-care ultrasound for assessment and cannulation of vascular access in haemodialysis. Exploratory descriptive cross-sectional web-based survey. Healthcare clinicians working in haemodialysis responsible for cannulation of arteriovenous fistula or grafts. The survey was completed by 645 health care clinicians from 38 countries. 75% to 93% of respondents from Australia/New Zealand, Canada, Europe and United Kingdom/Ireland reported access to ultrasound, compared to 26% (n = 43/167) from the United States respondent's reported lower levels of ultrasound training than other regions. Facilitators for using ultrasound were: the availability of ultrasound training (87%, n = 558), to reduce miscannulations (76%, n = 255/336) and to improve patient outcomes (73%, n = 246/336). Point-of-care ultrasound barriers were lack of access to ultrasound education (82%, n = 196/239), lack of ultrasound machines (33%, n = 212/645) or believing that ultrasound was someone else's role (38%, n = 29/86). This study revealed national and regional differences related to haemodialysis point-of-care ultrasound. Understanding the regions requiring more education and implementation of ultrasound and what motivates staff, or deters from using ultrasound, is crucial for effectiveness of future implementation and workplace change initiatives.

Advancing Renal Amyloidosis Care: The Role of Modern Diagnostic Techniques with the Potential of Enhancing Patient Outcomes.

Renal amyloidosis is a set of complex disorders characterized by the deposition of amyloid proteins in the kidneys, which causes gradual organ damage and potential kidney failure. Recent developments in diagnostic methods, particularly mass spectrometry and proteome profiling, have greatly improved the accuracy of amyloid typing, which is critical for disease management. These technologies provide extensive insights into the specific proteins involved, allowing for more targeted treatment approaches and better patient results. Despite these advances, problems remain, owing to the heterogeneous composition of amyloid proteins and the varying efficacy of treatments based on amyloid type. Access to sophisticated diagnostics and therapy varies greatly, highlighting the global difference in renal amyloidosis management. Future research is needed to investigate next-generation sequencing and gene-editing technologies, like clustered regularly interspaced short palindromic repeats (CRISPR), which promise more profound insights into the genetic basis of amyloidosis.

#1377 Evaluation of state-wide health system implementation of renal supportive care shows substantial net benefits

Abstract Background and Aims In 2016, the New South Wales (NSW) Health system implemented a service to make the principles and practice of palliative medicine comprehensively available to patients receiving chronic kidney disease (CKD) care across NSW. Summative evaluation of the economic value that this multi-disciplinary State-wide RSC service provided following implementation was prospectively planned in the domains of patient experience and economic value. This abstract reports the first cost-benefit analysis of a RSC service. Method De-identified patient-level data was extracted from the NSW Renal Supportive Care Register (a linked dataset comprising admitted patient, non-admitted patient, emergency department episodes and death registrations). Data was compared between 2015/16, prior to implementation of the State-wide RSC service; and 2018/19, following settled operation of the service. A cost-benefit analysis model was constructed to estimate the economic value of the RSC service between 2015/16 and 2018/19; and the projected value to 2029/30 under different scenarios. Multivariate Cox regressions were estimated to measure survival benefits, and a polynomial regression model was employed to estimate the impact of RSC on the share of patients receiving dialysis. Results Considering the actual impact of the NSW RSC service; in 2015/16, 5% (n = 443) of all ESKD patients, (defined as receiving dialysis &amp;gt;3 months, non-dialysis conservative care or in receipt of a functioning transplant) received any RSC service. By 2018/19, 16% (n = 1460) of all ESKD patients had received RSC within NSW. The proportion of patients receiving RSC from a non-dialysis conservative care or dialysis context remained stable between 2015/16 and 2018/19 at 41% and 29% respectively. Patients receiving RSC were estimated to have increased survival by 3-21 weeks, depending on patient characteristics, compared to the scenario of no RSC service. Considering the projected value of ongoing RSC services; scenarios with different assumptions were modelled. Assuming that the proportion of patients receiving different ESKD modalities and the costs of care remained stable, the RSC service would deliver a net financial benefit to the commissioning health system (avoided costs of service minus RSC costs) of ${\$}$109 million Australian Dollars (AUD), with a return on investment of 212%, compared to the scenario of no RSC service. When the economic value for the whole NSW community from increased survival benefit was included, the projected value was ${\$}$275 million AUD, with return on investment of 535%. The projected economic value of RSC was modelled under scenarios of increasing access to the service by ESKD patients (Figure). Increasing RSC access from the achieved 16% to 20% of ESKD patients was projected to deliver maximal economic value, with a 3% fall in ESKD patients receiving dialysis, increasing survival benefit (${\$}$221 million AUD) and economic value ${\$}$94 million AUD. As access to RSC expands further, modelling indicates that additional dialysis substitution becomes less likely but benefits still accrue from survival up to a maximum viable rollout of 50% of the ESKD population receiving RSC, when survival benefits plateau. Conclusion Economic evaluation of this implementation of the Statewide RSC service across NSW Health shows it has been associated with both a net economic benefit and survival benefits four years after implementation. It is projected to provide an economic value of ${\$}$275 million AUD over ten years, which would increase with greater participation of ESKD patients suitable for RSC.