Getting the most out of remote care: Co-developing a Toolkit to improve the delivery of remote kidney care appointments for underserved groups.

BACKGROUND: Telephone and video appointments are still common post-pandemic, with an estimated 25%-50% of kidney appointments in the United Kingdom still conducted remotely. This is important as remote consultations may exacerbate pre-existing inequalities in those from underserved groups. Those from underserved groups are often not represented in health research and include those with learning disability, mental health needs, hearing/sight problems, young/older people, those from ethnic minority groups. OBJECTIVES: The aim was to develop a Toolkit to improve the quality of remote kidney care appointments for people from different underserved groups. DESIGN: A parallel mixed methods approach with semistructured interviews/focus groups and survey. We also conducted workshops to develop and validate the Toolkit. PARTICIPANTS: Seventy-five renal staff members completed the survey and 21 patients participated in the interviews and focus groups. Patients (n = 11) and staff (n = 10) took part in the Toolkit development workshop, and patients (n = 13) took part in the Toolkit validation workshop. RESULTS: Four themes from interviews/focus groups suggested areas in which remote appointments could be improved. Themes were quality of appointment, patient empowerment, patient-practitioner relationship and unique needs for underserved groups. Staff reported difficulty building rapport, confidentiality issues, confidence about diagnosis/advice given, technical difficulties and shared decision making. CONCLUSION: This study is the first to explore experiences of remote appointments among both staff and those from underserved groups living with kidney disease in the United Kingdom. While remote appointments can be beneficial, our findings indicate that remote consultations need optimisation to meet the needs of patients. The project findings informed the development of a Toolkit which will be widely promoted and accessible in the United Kingdom during 2024.

Exploring Preconceptions as Barriers to Peritoneal Dialysis Eligibility: A Global Scenario-Based Survey of Kidney Care Physicians.

Introduction: Despite the growing number of patients requiring kidney replacement therapy (KRT), peritoneal dialysis (PD) is underutilized globally. A contributory factor may be clinician myths about its use. The aim of this study was to explore perceptions about PD initiation by clinicians according to various physical, social, and clinical characteristics of patients. Methods: An online global survey (in English and Thai) was administered to ascertain nephrologists' and nephrology trainees' decisions on recommending PD as a treatment modality. Results: A total of 645 participants (522 nephrologists and 123 trainees; 56% male) from 54 countries (66% from high-income countries [HICs], 22% from upper middle-income countries [UMICs], 12% from lower middle-income countries, and 1% from low-income countries [LICs]) completed the survey. Of the respondents, 81% identified as attending physicians or consultants, and 19% identified as trainees or other. PD was recommended for most scenarios, including repeated exposures to heavy lifting, swimming (especially in a private pool and ocean), among patients with cirrhosis or cognitive impairment with available support, and those living with a pet if a physical separation can be achieved during PD. Certain abdominal surgeries were more acceptable to proceed with PD (hysterectomy, 90%) compared to others (hemicolectomy, 45%). Similar variation was noted for different types of stomas (nephrostomies, 74%; suprapubic catheters, 53%; and ileostomies, 27%). Conclusion: The probability of recommending PD in various scenarios was greater among clinicians from HICs, larger units, and consultants with more clinical experience. There is a disparity in recommending PD across various clinical scenarios driven by experience, unit-level characteristics, and region of practice. Globally, evidence-informed education is warranted to rectify misconceptions to enable greater PD uptake.

Do we practice what we preach? Dialysis modality choice among healthcare workers in the United Kingdom.

BACKGROUND: In the United Kingdom, over 80% of end-stage kidney disease patients receive in-center hemodialysis. We conducted a survey of UK renal healthcare workers on their preferred dialysis modality if they needed dialysis themselves. METHODS: An anonymized online survey was disseminated to all renal healthcare workers in the United Kingdom. We asked "Assume you are an otherwise well 40-year-old (and, separately, 75-year-old) person approaching end stage kidney disease, you have no living kidney donor options at present. There are no contraindications to any dialysis options. Which dialysis therapy would you choose?" We also asked about factors influencing their choice. RESULTS: 858 individuals with a median age of 44.3 years responded. 70.2% were female, 37.4% doctors, and 31.1% were senior nurses. There was a preference for peritoneal dialysis over in-center hemodialysis (50.47% v. 6.18%; p < 0.001 for 40-year-old and 49.18% v. 17.83%; p < 0.001 for 75-year-old assumption) and home hemodialysis (50.47% v. 39.28%; p < 0.001 for 40-year-old and 49.18% v. 18.41% for 75-year-old assumption). There was a preference for home hemodialysis over in-center hemodialysis for 40-year-old (39.28% v. 6.18%; p < 0.001) but not for 75-year-old. On logistic regression, senior doctors were more likely to opt for PD when compared to nurses. Nurses, allied healthcare professionals, and those of Asian/British Asian ethnicity were more likely to choose in-center hemodialysis. CONCLUSIONS: Most healthcare workers in renal medicine would choose home-based treatment for themselves although the majority of end-stage kidney disease patients receive in-center hemodialysis in the United Kingdom; the reasons for the discrepancy need to be explored.

Dialysis education and options for late presenters-An ongoing dilemma.

Pre-dialysis education forms a crucial part of dialysis preparation. Acute start dialysis patients often commence and remain on in-center hemodialysis (ICHD) without the benefit of an informed decision making process for kidney replacement therapy options. The aim of this review is to evaluate the evidence surrounding methods of education provision to the acute dialysis start population and their associated outcomes. Publications have described a holistic education pathway with multimedia provision of information and interactive experiences. One or more trained specialist nurses provided information over 3-5 sessions. Formal education was mostly initiated as an inpatient. 86%-100% of acute start dialysis patients are initiated and remain on ICHD. Following formal education, 21%-58% of patients chose peritoneal dialysis (PD), 10%-24% home hemodialysis, 33%-58% ICHD. This brings the number of patients maintained on an independent form of dialysis similar to the planned dialysis start population. Patients commenced on PD without needing temporary hemodialysis, hence avoided complications associated with such. Patients aged under 75 (p < 0.0001) and males (p = 0.006) were more likely to be influenced by education to select PD. The adjusted 5 year survival rates among discharged patients were similar between home and ICHD groups (73% vs. 71% respectively), with a comparable age of death. A targeted education program in the acute dialysis start population has proven to be feasible. Adaptations are likely required for each center; however, various methods have been shown to be effective, with an increased number of patients choosing an independent dialysis modality when given the choice.

Focal Segmental Glomerulosclerosis Complicating Therapy With Inotersen, an Antisense Oligonucleotide Inhibitor: A Case Report.

Inotersen is an antisense oligonucleotide inhibitor licensed for the treatment of polyneuropathy complicating hereditary transthyretin amyloidosis (ATTRv). Nephrotoxicity has been reported with inotersen, including progression to kidney failure. We describe what is to our knowledge the first reported case of inotersen-associated nephrotic syndrome secondary to focal segmental glomerulosclerosis (FSGS) and review the literature concerning inotersen-induced nephrotoxicity. We report a woman in her early 30s with ATTRv associated with the V50M transthyretin (TTR) variant, who presented with nephrotic syndrome 7 months after commencement of inotersen. Renal histology demonstrated FSGS and scanty glomerular amyloid deposition. Discontinuation of inotersen alone resulted in complete clinical and biochemical resolution of nephrotic syndrome. Inotersen is associated with significant nephrotoxicity. In the phase 3 NEURO-TTR clinical trial, 3% of patients in the treatment arm developed a crescentic glomerulonephritis. All affected patients carried the V50M TTR variant, which is known to be associated with renal amyloid deposition. This case adds to the spectrum of kidney disease associated with inotersen and indicates that discontinuation of the drug alone may result in resolution of renal complications without additional immunosuppression. Monitoring of kidney function is essential in patients with ATTRv receiving inotersen, particularly if there is evidence of existing renal amyloid.

Using root cause analysis as a tool to reduce central venous catheters in haemodialysis patients.

BACKGROUND: Haemodialysis remains the most common modality of renal replacement therapy. National and international guidelines continue to promote arteriovenous fistulas or grafts as the preferred vascular access for haemodialysis, given the increased risks associated with use of central venous catheters (CVCs). Our renal centre pursues a 'fistula first' culture and uses root cause analysis and a patient safety incident based approach to meet the recommended standards of minimal CVC use in dialysis patients. METHODS: We undertook a retrospective observational review looking at patterns of CVC use amongst our patients to identify themes and changes over time. Using data collected over a 5 year period, we examined 100 patient safety incidents involving CVC use in planned haemodialysis patients. We used a contributory factors framework to identify systemic contributors to each incident. RESULTS: During the study period our centre achieved the national standard of at least 60% of incident dialysis patients commencing planned haemodialysis via arteriovenous access. About 26% of cases of CVC use in incident dialysis patients were deemed potentially avoidable. The most common contributory factor identified in these cases was poor communication. CONCLUSIONS: Using a root cause analysis based methodology to examine CVC use in haemodialysis is a novel approach to quality improvement in this area. Our methodology can be used as a framework by other centres to optimise the provision of safe, effective, and timely vascular access for dialysis, with multiple benefits for both renal services and individual patients.

Regional variations in nephrology trainee confidence with clinical skills may relate to the availability of local training opportunities in the UK: results from a national survey.

BACKGROUND: The United Kingdom offers a standardised training program for nephrology fellows. However, local training opportunities vary resulting in mismatches between trainee interests and accessible opportunities. This may impact trainee confidence, satisfaction, and future service provision. METHODS: A survey assessing confidence with key procedures and sub-specialities was disseminated. Associations with region of training were probed using Chi square tests, with significance set at p < 0.0008 following a Bonferroni correction. Results were compared to trainee views on available opportunities for development. RESULTS: 139 responses were received (32% response rate, demographics representative of the UK nephrology trainee cohort). Procedural independence varied from 98% for temporary femoral vascular catheters to 5% for peritoneal dialysis catheters (PDIs). Independence with inserting tunnelled vascular catheters varied with region (p < 0.0001). Trainees expressed a desire for formal training in kidney ultrasound scanning and PDIs, corresponding with procedures they had least opportunity to become independent with. Trainees felt least confident managing kidney disease in pregnancy. Suggestions for improving training included protected time for garnering sub-speciality knowledge, developing procedural skills and for experiencing practice in other nephrology units. CONCLUSIONS: A mismatch between trainee interests and professional development opportunities exists, which may threaten trainee autonomy and impact patient care particularly with regards to peritoneal dialysis. Provisions to facilitate trainee directed development need to be made while balancing the rigors of service provision. Such measures could prove critical to promoting trainee well-being and preventing attrition within the nephrology workforce.

A Quality Improvement Process to Increase and Sustain a Peritoneal Dialysis Programme in the United Kingdom.

INTRODUCTION: Peritoneal dialysis (PD) remains underutilised in the West. The proportion of patients in the UK starting renal replacement therapy (RRT) with PD fell from 7.2% in 2011 to 6.0% in 2016. At our centre, 8.4% of dialysis patients received PD in April 2014. Evidence suggests that home dialysis improves patient clinical outcomes; therefore, a target was agreed to achieve 25% of dialysis patients receiving PD by 2018. METHODS: A rapid improvement process was introduced, as a quality improvement tool, to increase and sustain the PD programme. With multidisciplinary team support for PD growth, a nephrologist was trained to insert PD catheters. Nurses were trained to provide patients with balanced pre-dialysis information and discuss alternative dialysis modalities with haemodialysis (HD) patients. The "Acceptance, Choice and Empowerment" project raised awareness of home therapy choices, using a peer educator model specifically for ethnic minority patients. Lean methodologies were used to ensure continuous quality improvement. RESULTS: PD uptake increased from 37 to 84 patients, giving a PD penetration increase from 8.4% to 19.1% between April 2014 and March 2018. Catheter insertions increased from 94 at the end of QI Period 1 to 185 at the end of QI Period 2, representing a 97% increase, with the medical/surgical split remaining stable. Peritonitis rates remained stable, and PD drop off to HD reduced from 52% to 41% during the same period. CONCLUSIONS: By implementing a rapid improvement process and embedding a quality improvement programme, the number of incidents and prevalent PD patients increased and was sustained.

Patient perspectives and experiences of remote consultations in people receiving kidney care: A scoping review.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic resulted in a rapid and sometimes chaotic change in how clinical care was delivered for people living with kidney disease, with increased reliance on digital technologies and the introduction of remote services. OBJECTIVES: To conduct a scoping review of studies about patients' experiences and perspectives in receipt of remote consultations for kidney care. DESIGN: Using Arksey and O'Malley's framework, three databases were searched on EBSCO (CINAHL, MEDLINE and Psych INFO). The search included studies published in English from August 2010 to August 2021. RESULTS: Eight studies met the scoping review criteria (two cross-sectional, two mixed-method and four qualitative). Five themes were identified: overall satisfaction with remote services, benefits to patients (convenience, involvement in care and patient safety), barriers to remote consultations (technical difficulties, digital literacy and loss of interpersonal communication), patient concerns (need for physical examination, privacy and confidentiality) and prerequisites for successful remote care (existing patient-practitioner relationship, stable illness phase and access to technology). CONCLUSION: Remote consultations confer multiple advantages to patients; therefore, remote consultations should be offered as an option to patients living with kidney disease beyond the COVID-19 pandemic. However, there are several barriers to remote consultation that need to be addressed and understood before implementing remote care long-term. Future research should examine the impact of remote consultations on people living with kidney disease from under-served groups to identify barriers and ensure their suitability and accessibility to the wider population for a more patient-centred approach to kidney care.

End-stage kidney disease patients from ethnic minorities and mortality in coronavirus disease 2019.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) adversely affects patients who are older, multimorbid, and from Black, Asian or minority ethnicities (BAME). We assessed whether being from BAME is independently associated with mortality in end-stage kidney disease (ESKD) patients with COVID-19. METHODS: Prospective observational study in a single UK renal center. A study was conducted between March 10, 2020 and April 30, 2020. Demographics, socioeconomic deprivation (index of multiple deprivation), co-morbidities (Charlson comorbidity index [CCI]), and frailty data (clinical frailty score) were collected. The primary outcome was all-cause mortality. Data were censored on the 1st June 2020. FINDINGS: Overall, 191 of our 3379 ESKD patients contracted COVID-19 in the 8-week observation period; 84% hemodialysis, 5% peritoneal dialysis, and 11% kidney transplant recipients (KTR). Of these, 57% were male and 67% were from BAME groups (43% Asian, 17% Black, 2% mixed race, and 5% other). Mean CCI was 7.45 (SD 2.11) and 3.90 (SD 2.10) for dialysis patients and KTR, respectively. In our cohort, 60% of patients lived in areas classified as being in the most deprived 20% in the United Kingdom, and of these, 77% of patients were from BAME groups. The case fatality rate was 29%. Multivariable cox regression demonstrated that BAME (hazard ratio [HR]: 2.37, 95% CI: 1.22-4.61) was associated with all-cause mortality after adjustment for age, deprivation, co-morbidities, and frailty. Associations with all-cause mortality persisted in sensitivity analyses in patients from South Asian (HR: 2.52, 95% CI: 1.24-5.12) and Black (HR: 2.43, 95% CI: 1.04-5.67) ethnic backgrounds. DISCUSSION: BAME ESKD patients with COVID-19 are just over twice as likely to die compared to White patients, despite adjustment for age, deprivation, comorbidity, and frailty. This study highlights the need to develop strategies to improve BAME patient outcomes in future outbreaks of COVID-19.

Peritoneal dialysis patients - the forgotten group in the coronavirus pandemic.

While all patients with chronic disease have undoubtedly been affected by the ongoing SARS-CoV-2 (COVID-19) pandemic, individuals with end-stage renal failure have suffered significant excess morbidity and mortality. Patients on haemodialysis have received extensive research and media attention into their vulnerability to the disease; however, those receiving peritoneal dialysis (PD) have been much less visible. We surveyed a selection of patients from a cohort receiving PD at a tertiary renal unit in Birmingham, UK. We devised a questionnaire looking at patients' experience of shielding, accessing both dialysis and general medical care during the pandemic, and their thoughts about the pandemic and the future. Concerning findings were apparent from this. Attending hospital was the most commonly cited reason for being unable to shield, and multiple patients experienced difficulties accessing care while unwell during this period. Worryingly, 58% of respondents indicated that they feel negatively, or feel ambivalent, about the future. Patients receiving PD have suffered significantly during the COVID-19 pandemic and face ongoing difficulties and risks while accessing medical care. It is vital that this cohort is not forgotten in the planning of renal services during the pandemic, and that special attention is paid to both their physical and mental health.

Effects of hemodialysis access surveillance on reducing risk of hemodialysis access thrombosis: A meta-analysis of randomized studies.

INTRODUCTION: Vascular access thrombosis remains the Achilles Heel for many a hemodialysis patient. We performed a systematic review and meta-analysis to assess the impact of monitoring vascular access blood flow on prediction and prevention of vascular access thrombosis. We hypothesized that monitoring vascular access blood flow has a pivotal role in lowering the risk of thrombosis and subsequent access failure. METHODOLOGY: We conducted a systematic review in PubMed and EMBASE databases to identify randomized studies that have assessed the effect of hemodialysis access surveillance on the risk of thrombosis. A random-effects model was used for the meta-analysis. Subgroup analysis was performed among patients with arterio-venous fistula (AV-fistulas) and those with arterio-venous graft (AV-grafts). RESULTS: Ten randomized studies were included in the meta-analysis. The total number of patients included in the analysis was 1430. On performing the random-effects model among the included studies, hemodialysis access surveillance was associated with better outcomes (risk ratio = 0.73, 95% confidence interval ranges from 0.55 to 0.98). The analysis of the AV-fistula group showed an estimated overall risk ratio of 0.55 (95% confidence interval ranges from 0.33 to 0.89) favoring access surveillance. However, in the AV-grafts group, the estimated overall risk ratio was 0.92 (95% confidence interval ranges from 0.65 to 1.29) showing no additional benefit for access surveillance. CONCLUSION: Hemodialysis access surveillance using access blood flow monitoring can reduce the risk of access thrombosis for patients with AV-fistulas, but this is not the case with AV-grafts.

The effects of dialysis modality choice on cognitive functions in patients with end-stage renal failure: a systematic review and meta-analysis.

INTRODUCTION: Cognitive dysfunction is a major consequence of end-stage renal disease (ESRD) and has further detrimental effects on both functionality and the quality of life for patients. While peritoneal dialysis is generally advocated in ESRD, there is a substantial knowledge gap about the differential effects of chronic dialysis modalities on cognitive dysfunction and decline. The aim of this meta-analysis is to evaluate cognitive function in peritoneal dialysis versus hemodialysis patients. METHODS: We performed a systematic review in different databases to identify studies that assessed the effect of different dialysis modalities on cognitive functions. Inclusion criteria for our meta-analysis were all studies that compared the effects of peritoneal dialysis on cognitive functions compared to intermittent hemodialysis. The data collected were the name of the first author, journal title, year of publication, country where the study was conducted, number of patients in the peritoneal dialysis and hemodialysis arms and methods of assessment of cognitive functions. RESULTS: Out of 2769 abstracts reviewed in different databases, 11 papers were included in our meta-analysis. Altogether, 195,774 patients were included in the final analysis. The forest plot analysis of the rate of cognitive impairment in different dialysis modalities showed decreased risk of cognitive impairment in the peritoneal dialysis population compared to hemodialysis patients (relative risk = 0.634, confidence interval ranges from 0.508 to 0.790). There was evidence of significant heterogeneity among studies with p < 0.0001 and I2 = 85.5%. The sensitivity analysis limited to studies on patients younger than 65 years of age showed similar results (relative risk = 0.516; 95% confidence intervals: 0.379-0.704). CONCLUSION: Patients on peritoneal dialysis demonstrated a lower odd of cognitive dysfunction compared to those on hemodialysis. Future prospective studies should assess cognitive decline as a meaningful outcome in dialysis patients.