Left-sided valvular heart disease in dialysis recipients: a single-centre observational study.

Background: With the increasing prevalence of chronic kidney disease, the number of people receiving renal replacement is expected to increase by 50% by 2030. Cardiovascular mortality remains significantly higher in this population. The presence of valvular heart disease (VHD) in patients with end-stage renal disease is associated with poor survival. In a dialysis cohort, we assessed the prevalence and characteristics of patients with significant VHD, the association with clinical parameters and the impact on survival. Methods: Echocardiographic parameters for dialysis recipients from a single centre in the UK were collected. Significant left-sided heart disease (LSHD) was defined as moderate or severe left valvular lesions or left ventricular systolic dysfunction (LVSD) (ejection fraction <45%) or both. Baseline demographic and clinical characteristics were ascertained. Results: In 521 dialysis recipients {median age 61 years [interquartile range (IQR) 50-72], 59% male}, 88% were on haemodialysis and the median dialysis vintage was 2.8 years (IQR 1.6-4.6). A total of 238 (46%) had evidence of LSHD: 102 had VHD, 63 had LVSD and 73 had both. Overall, 34% had evidence of left-sided VHD. In multivariable regression analysis, age and use of cinacalcet were associated with higher odds of VHD {odds ratio [OR] 1.03 [95% confidence interval (CI) 1.02-1.05] and OR 1.85 [95% CI 1.06-3.23], respectively}, while the use of phosphate binders was associated with increased odds of aortic stenosis [AS; OR 2.64 (95% CI 1.26-5.79)]. The 1-year survival was lower in VHD [78% versus 86% (95% CI 0.72-0.84 and 0.83-0.90), respectively] and in LSHD [78% versus 88% (95% CI 0.73-0.83 and 0.85-0.92), respectively]. In AS, the 1-year survival was 64% (95% CI 0.49-0.82). Using propensity score matching to adjust for age, diabetes and low serum albumin, AS was significantly associated with lower survival (P = .01). LSHD was significantly associated with worse survival (P = .008) compared with survival in LVSD (P = .054). Conclusion: A high proportion of dialysis patients have clinically significant LSHD. This was associated with higher mortality. In valvular heart disease, the development of AS is independently associated with higher mortality in dialysis patients.

Clinical triage of patients on kidney replacement therapy presenting with COVID-19: an ERACODA registry analysis.

BACKGROUND: Patients on kidney replacement therapy (KRT) are at very high risk of coronavirus disease 2019 (COVID-19). The triage pathway for KRT patients presenting to hospitals with varying severity of COVID-19 illness remains ill-defined. We studied the clinical characteristics of patients at initial and subsequent hospital presentations and the impact on patient outcomes. METHODS: The European Renal Association COVID-19 Database (ERACODA) was analysed for clinical and laboratory features of 1423 KRT patients with COVID-19 either hospitalized or non-hospitalized at initial triage and those re-presenting a second time. Predictors of outcomes (hospitalization, 28-day mortality) were then determined for all those not hospitalized at initial triage. RESULTS: Among 1423 KRT patients with COVID-19 [haemodialysis (HD), n = 1017; transplant, n = 406), 25% (n = 355) were not hospitalized at first presentation due to mild illness (30% HD, 13% transplant). Of the non-hospitalized patients, only 10% (n = 36) re-presented a second time, with a 5-day median interval between the two presentations (interquartile range 2-7 days). Patients who re-presented had worsening respiratory symptoms, a decrease in oxygen saturation (97% versus 90%) and an increase in C-reactive protein (26 versus 73 mg/L) and were older (72 vs 63 years) compared with those who did not return a second time. The 28-day mortality between early admission (at first presentation) and deferred admission (at second presentation) was not significantly different (29% versus 25%; P = 0.6). Older age, prior smoking history, higher clinical frailty score and self-reported shortness of breath at first presentation were identified as risk predictors of mortality when re-presenting after discharge at initial triage. CONCLUSIONS: This study provides evidence that KRT patients with COVID-19 and mild illness can be managed effectively with supported outpatient care and with vigilance of respiratory symptoms, especially in those with risk factors for poor outcomes. Our findings support a risk-stratified clinical approach to admissions and discharges of KRT patients presenting with COVID-19 to aid clinical triage and optimize resource utilization during the ongoing pandemic.

A simplified, rapid LC-MS/MS assay for serum and salivary creatinine.

In routine clinical laboratories, serum creatinine is typically measured on automated analyzers using colorimetric or enzymatic assays, which are both susceptible to interferences that can lead to incorrect measurement. Here, we present a straightforward and rapid LC-MS/MS assay for serum creatinine using methanol extraction, with separation performed using a strong cation exchange column. Results from this newly developed method were compared against those from an automated Abbott Architect kinetic Jaffe method. We also assessed the effect of bilirubin and glucose, as interferants, on both methods. Our LC-MS/MS assay has a run time of 1.1 min, uses a relatively small sample volume of 10 µL and has a within-batch imprecision of 1.1-1.8% at the concentrations tested, which is within the range necessary for routine clinical use. Recovery from serum samples spiked with creatinine was >95%, and glucose and bilirubin were not found to interfere in the assay. Glucose was observed to significantly interfere in the kinetic Jaffe method, while bilirubin had a variable effect. We also determined that creatinine can be measured from saliva using our method, and that salivary concentrations are, on average, 15% of those in serum. This assay provides an alternative for patient sample analysis where interference is expected in routine creatinine methods.

Attitudes of nephrologists towards intensified hemodialysis
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AIMS: Intensified hemodialysis (HD) programs have been developed to overcome the shortcomings of conventional HD. However, there are no data on the implementation of intensified HD programs into routine care. Therefore, we investigated the attitude of nephrologists towards intensified HD, its penetrance into clinical practice, and barriers to implementation. MATERIALS AND METHODS: We performed an online survey within the German Society of Nephrology on the beliefs and attitudes towards intensified HD. RESULTS: 44% of the respondents believe that there is sufficient evidence in favor of intensified HD independent of whether the respondent offers intensified HD or not. Before expanding intensified HD, adequate funding (81%) and more staff (60%) are needed. 44% of the respondents offer intensified HD to their patients. The offer of intensified HD is made to the patients mainly if the patient is not adequately treated with conventional HD (50%); only 19% offer it routinely to all patients with CKD stage 4, in preparation for renal replacement therapy. 33% of the respondents offer short daily HD, 70% nocturnal intermittent, and 4% daily nocturnal. In 30% of the respondent centers, intensified dialysis is performed at home. CONCLUSION: Nearly one-half of the respondents already offer intensified HD. Inappropriate funding of intensified HD programs represents the most important barrier for further implementation.
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How an ordeal becomes the norm: A qualitative exploration of experiences of self-cannulation in male home haemodialysis patients.

OBJECTIVES: Despite home haemodialysis (HHD) being associated with significant health and psychosocial benefits, it remains an under-utilized dialysis modality for people with chronic kidney disease. Self-cannulation, where patients insert their own needles for dialysis, is a key component of HHD. Recent research suggests that the prospect of self-cannulation is a barrier for patients, but there is little research which examines why this is the case. The aim of this study was to explore male HHD patients' experiences and attitudes towards self-cannulation. DESIGN: Qualitative methods were adopted to gather in-depth views from experienced HHD patients from a UK renal centre. METHODS: Semi-structured interviews were conducted with eight male HHD patients (HHD duration: 12-55 months). During the interview, the researcher elicited participants' lived experience of self-cannulation. Topics included the decision to self-cannulate and the impact of self-cannulation on the patient. The data collected were analysed using interpretative phenomenological analysis. RESULTS: The findings from this study elucidate the process of how self-cannulation changed from an ordeal to the norm in these participants' lives. The central theme from these interviews is that 'becoming a person who self-cannulates is a process'. Three super-ordinate themes were discussed that relate to this central theme: 'gaining control', 'building confidence', and 'becoming the norm'. CONCLUSIONS: The findings from this study suggest that some patients' initial fears of self-cannulation can be overcome. These findings offer health care professionals and patients alike a greater understanding of how patients who self-cannulate conceptualize it and its role in their mental and physical health. Statement of contribution What is already known on this subject? Home haemodialysis is a cost-effective form of renal replacement therapy which is under-utilized in the United Kingdom. Home haemodialysis is associated with positive health outcomes. Self-cannulation is noted as a barrier to home haemodialysis. What does this study add? Describes the process by which male dialysis patients became proficient in self-cannulation. Highlights psychological mechanisms which may facilitate and maintain self-cannulation. Suggests practical techniques which can be incorporated into renal clinics and care plans.

Barriers for implementation of intensified hemodialysis: survey results from the International Pediatric Dialysis Network.

BACKGROUND: In patients on conventional hemodialysis (HD), morbidity is high and quality of life is poor. Intensified HD programs have been developed to help overcome these shortcomings, , but very few pediatric dialysis centers have reported the implementation of such a HD program. METHODS: An online survey was sent to all 221 pediatric dialysis centers which participate in the International Pediatric Dialysis Network (IPDN). The aim of the survey was to assess the attitude of pediatric nephrologists towards intensified HD, the penetrance of intensified HD into their clinical practice and barriers to implementation. RESULTS: Of the 221 pediatric dialysis centers sent the survey, respondents from 61% (134) replied. Among these respondents, 69% acknowledged being aware of the evidence in support of the use of intensified HD, independent of whether intensified HD was offered at their own center, and 50% associated the use of daily nocturnal HD with the best overall patient outcome. In contrast, only 2% of respondents were in favor of conventional HD. Overall, 38% of the respondents stated that at their center intensified HD is prescribed to a subgroup of patients, most commonly in the form of short daily HD sessions. The most important barriers to expansion of intensified HD programs were lack of adequate funding (66%) and shortage of staff (63%), whereas lack of expertise and of motivation were reported infrequently as obstacles (21 and 14%, respectively). CONCLUSION: Intensified HD is considered by many pediatric nephrologists to be the dialysis modality most likely associated with the best patient outcome. The limited use of this treatment approach highlights the importance of defining and successfully addressing the barriers to implementation.

Multidisciplinary staff attitudes to home haemodialysis therapy.

Background: More than a decade after the National Institute for Health and Clinical Excellence recommendation of home haemodialysis (home HD) for 10-15% of those needing renal replacement therapy, the uptake across different regions in the UK remains uneven. Methods: This survey is part of the Barriers to Successful Implementation of Care in Home Haemodialysis (BASIC-HHD) study, an observational study of patient and organizational factor barriers and enablers of home HD uptake, in the UK. The study centres had variable prevalence of home HD by design [low: <3% (2), medium: 5-8% (2) and high: >8% (1)]. This survey was administered electronically in 2013, and had 20 questions pertaining to home HD beliefs and practices. A total of 104 members of staff across five study centres were approached to complete the survey. Results: The response rate was 46%, mostly from experienced HD practitioners. Most believed in the benefits of home HD therapy. Across all centres, respondents believed that preconceptions about patients' and carers' ability to cope with home HD (35% to a great or very great extent) and staff knowledge and bias influenced offer of home HD therapy (45%). Also, compared with respondents from high prevalence (HP) centre, those from low prevalence (LP) centres felt that display and presentation of dialysis information lacked clarity and uniformity (44% versus 18%), and that a better set-up for training patients for self-care HD was required (72.8% versus 33.3%). A greater proportion of respondents from the HP centre expressed concerns over caregiver support and respite care for patients on home HD (63.7% versus 33.3%). Conclusions: Survey results indicate that across all centres in the study, there is an appetite for growing home HD. There are some differences in attitudes and practice between LP and HP centres. There are other domains where all centres have expressed concern and addressing these will be influential in navigating change from the current course.

The Influence of Renal Centre and Patient Sociodemographic Factors on Home Haemodialysis Prevalence in the UK.

BACKGROUND: In the United Kingdom, socioeconomic disadvantage has been associated with lower use of home dialysis, mostly peritoneal dialysis. In this study, we explore the role of a patient's sociodemographic, socioeconomic differences and the centre's influence on home haemodialysis (HD) prevalence. METHODS: Data is derived from the cross-sectional arm of the UK multi-centre study investigating barriers and enablers of home HD (BASIC-HHD study). Centres were classified as low- (<3%), medium- (5-8%) and high-prevalence groups (>8%). Sociodemographic and socioeconomic status data were ascertained. Patients were enrolled in hospital HD (n = 213), home HD (n = 93) and predialysis groups (n = 222). RESULTS: The treating renal centre to which the patient belonged was significantly associated with a patient's modality in prevalent HD groups and modality-choice in the "predialysis" group, in confounder-adjusted multivariable analyses. Non-white ethnicity was associated with lower odds of self-care dialysis modality choice (OR 0.21, 95% CI 0.07-0.62) and lower odds of home HD uptake in the prevalent HD group (OR 0.24, 95% CI 0.07-0.80). Other significant associations of home HD uptake in the HD cohort included lower age (OR 0.59, 95% CI 0.39-0.89), higher education (OR 2.99, 95% CI 1.25-7.16), home ownership (OR 0.26, 95% CI 0.09-0.70), childcare responsibility (OR 0.22, 95% CI 0.08-0.66) and unrestricted mobility (OR 0.31, 95% CI 0.11-0.91). CONCLUSION: "Centre" effect accounts for variation in home HD prevalence between renal units after accounting for sociodemographic parameters and co-morbidities. Unit practices and attitudes to home HD are likely to have a dominating impact on home HD prevalence rates and these aspects need to be explored systematically at the organisational level.

Illness Beliefs in End Stage Renal Disease and Associations with Self-Care Modality Choice.

BACKGROUND: Interest in self-care haemodialysis (HD) has increased because it improves patients'clinical and quality-of-life outcomes. Patients who undertake self-management for haemodialysis may hold illness beliefs differently to those choosing institutional care at the time of making the modality choice or moulded by their illness and dialysis treatment experience. Illness perceptions amongst predialysis patients and in those undertaking fully-assisted and self-care haemodialysis are being investigated in a combined cross-sectional and longitudinal study. STUDY DESIGN: The study data are derived from the BASIC-HHD study, a multicentre observational study on factors influencing home haemodialysis uptake. 535 patients were enrolled into three groups: Predialysis CKD-5 group, prevalent 'in-centre' HD and self-care HD groups (93% at home). We explore illness perceptions in the cross-sectional analyses of the three study groups, using the revised Illness Perception Questionnaire (IPQ-R). Predialysis patients' illness beliefs were reassessed prospectively, typically between 4 and 12 months after dialysis commencement. RESULTS: Illness belief subscales are significantly different between in-centre and self-care HD groups. In a step-wise hierarchical regression analysis, after adjustment for age, education, marital status, diabetes, dialysis vintage, depression, anxiety scores, and IPQ-R subscales, personal control (p = 0.01) and illness coherence (p = 0.04) are significantly higher in the self-care HD group. In the predialysis group, no significant associations were found between illness representations and modality choices. In prospectively observed predialysis group, scores for personal control, treatment control, timeline cyclical and emotional representations reduced significantly after commencing dialysis and increased significantly for illness coherence. CONCLUSIONS: Illness beliefs differ between hospital and self-care haemodialysis patients. Patient's affect and neurocognitive ability may have an important role in determining illness beliefs. The impact of modality upon illness representations may also be significant and remains to be explored.

Time to recovery from haemodialysis : location, intensity and beyond.

INTRODUCTION: Prolonged recovery time (RT) affects patient's quality-of-life adversely. Shorter dialysis RT in home haemodialysis (HHD) noted in observational studies has been attributed to intensive dialysis regimens. Home patients adopt different haemodialysis (HD) schedules. There is insufficient literature on RT in HHD patients receiving different HD schedules. METHODS: Data was prospectively collected for BASIC-HHD study, a multicentre study of home and hospital HD across five tertiary centres in the UK. Two hundred and eighty-eight patients answered the question, 'how long does it take for you to recover from a haemodialysis session?' Ninety-one patients (31.8%) of study population performed HHD. Participants completed neuropsychometric tests and depression and anxiety screening inventories. RESULTS: Recovery time is longest amongst 'in-centre' HD recipients (Mean 193 min; SD 295.37) and significantly higher than the mean RT of home HD recipients (Mean 67.3 min; SD 86.8). Within the home setting, RT was not significantly different between the intensive HD and conventional HD (67.8 vs 66.5 min; P > 0.05) groups but higher residual urine volumes in the standard home group had significantly shorter RT. Location of HD, not intensity, remained significant (P = 0.001) in the unadjusted and adjusted multivariable analysis. Longer RT was associated with female gender, unemployed or retired 'work' status, 'non-white' ethnicity, lower predialysis systolic blood pressure and greater depression screening score. CONCLUSIONS: Home-based HD and higher residual urine volumes are significantly associated with shorter RT. This home advantage for RT may be sustained by preserving residual renal function (in early stages) and increasing HD intensity (in later stages) of dialysis therapy.

Healthcare decision-making in end stage renal disease-patient preferences and clinical correlates.

BACKGROUND: Medical decision-making is critical to patient survival and well-being. Patients with end stage renal disease (ESRD) are faced with incrementally complex decision-making throughout their treatment journey. The extent to which patients seek involvement in the decision-making process and factors which influence these in ESRD need to be understood. METHODS: 535 ESRD patients were enrolled into the cross-sectional study arm and 30 patients who started dialysis were prospectively evaluated. Patients were enrolled into 3 groups- 'predialysis' (group A), 'in-centre' haemodialysis (HD) (group B) and self-care HD (93 % at home-group C) from across five tertiary UK renal centres. The Autonomy Preference Index (API) has been employed to study patient preferences for information-seeking (IS) and decision-making (DM). Demographic, psychosocial and neuropsychometric assessments are considered for analyses. RESULTS: 458 complete responses were available. API items have high internal consistency in the study population (Cronbach's alpha > 0.70). Overall and across individual study groups, the scores for information-seeking and decision-making are significantly different indicating that although patients had a strong preference to be well informed, they were more neutral in their preference to participate in DM (p < 0.05). In the age, education and study group adjusted multiple linear regression analysis, lower age, female gender, marital status; higher API IS scores and white ethnicity background were significant predictors of preference for decision-making. DM scores were subdivided into tertiles to identify variables associated with high (DM > 70: and low DM (≤30) scores. This shows association of higher DM scores with lower age, lower comorbidity index score, higher executive brain function, belonging in the self-caring cohort and being unemployed. In the prospectively studied cohort of predialysis patients, there was no change in decision-making preference scores after commencement of dialysis. CONCLUSION: ESRD patients prefer to receive information, but this does not always imply active involvement in decision-making. By understanding modifiable and non-modifiable factors which affect patient preferences for involvement in healthcare decision-making, health professionals may acknowledge the need to accommodate individual patient preferences to the extent determined by the individual patient factors.

Self-cannulation for haemodialysis: patient attributes, clinical correlates and self-cannulation predilection models.

BACKGROUND AND OBJECTIVES: With emerging evidence in support of home haemodialysis (HHD), patient factors which determine uptake of the modality need to be better understood. Self-cannulation (SC) is a major step towards enabling self-care 'in-centre' and at home and remains the foremost barrier to its uptake. Human factors governing this aspect of HD practice are poorly understood. The aim of this study is to better understand self-cannulation preferences and factors which define them in end stage renal disease (ESRD). DESIGN: In this multicentre study, 508 of 535 patients from predialysis (Group A: n = 222), in-centre (Group B: n = 213), and home HD (Group C: n = 100) responded to a questionnaire with 3 self-cannulation questions. Simultaneously, data on clinical, cognitive and psychosocial variables were ascertained. The primary outcome measure was 'perceived ability to self-cannulate AV access'. Predictive models were developed using logistic regression analysis. RESULTS: 36.6% of predialysis patients (A) and 29.1% of the 'in-centre' haemodialysis patients (B) felt able to consider SC for HD. Technical-skills related apprehension was highest in Group B (14.4%) patients. Response to routine venepuncture and the types of SC concerns were significant predictors of perceived ability to self-cannulate. There was no significant difference in concern for pain across the groups. In multivariable regression analysis, age, education level, 3 MS score, hypoalbuminemia in Groups B & C and additionally, attitude to routine phlebotomy and the nature of specific concern for self-cannulation in Groups A, B and C, are significant predictors of SC preference. The unadjusted c-statistics of models 1 (derived from Group A and validated on A) and 2 (derived from B+C and validated on B), are 0.76(95% CI 0.69, 0.83) and 0.80 (95% CI 0.74, 0.87) respectively. CONCLUSIONS: There is high prevalence of perceived ability to self-cannulate. Modifiable SC concerns exist in ESRD. The use of predictive models to objectively define and target education and training strategies could potentially impact on HD self-management and future uptake of home HD.

An international feasibility study of home haemodialysis in older patients.

BACKGROUND: Home haemodialysis (HHD) is undergoing a significant revival. There is a global demographic shift with a rising mean age of dialysis patients. We postulated that intensive HHD may also benefit the older dialysis population. However, there is a lack of literature on the feasibility of HHD in older patients with end-stage renal disease (ESRD). The purpose of this study was to ascertain the feasibility of delivering HHD to older patients. METHODS: We conducted a multi-centre multinational retrospective cohort study of HHD patients ≥65 years of age at the time of HHD initiation; 79 patients were included. Baseline demographic data included age at start of dialysis, race and sex. Dialysis characteristics including total weekly treatment hours, need for assistance, training time, dialysis access, modality and dialysis vintage were captured, as well as cause of ESRD and medical co-morbidities. The primary outcome was time to technique failure or death. Rates of hospitalization, cardiovascular events, non-infectious vascular access events and infections were collected. RESULTS: Median age at start was 68 (interquartile range 66-71) years. An arteriovenous fistula was the predominant access, and most patients were receiving <16 h of total weekly dialysis treatment. Family or nurse assistance for dialysis was required in 54% of patients. There were 17 (22%) deaths and 20 (26%) technique failures. The cumulative time at risk was 188 years. Event-free survival at 1, 2 and 5 years was 85, 77 and 24%, respectively, and technique survival was 92, 83 and 56%, respectively. Advancing age (categorized into quartiles) was an unadjusted risk factor for death and technique failure. CONCLUSIONS: This analysis confirms feasibility of HHD in patients 65 years or older at the start of this modality and should foster further research on the potential benefits of (intensive) HHD in older ESRD patients.

Home hemodialysis: beliefs, attitudes, and practice patterns.

There is increasing interest of the worldwide kidney community in home hemodialysis (HHD). This is due to emerging evidence of its superiority over conventional hemodialysis (HD), largely attributed to improved outcomes on intensive schedule HD, best deployed in patient's own homes. Despite published work in this area, universal uptake remains limited and reasons are poorly understood. All those who provide HD care were invited to participate in a survey on HHD, initiated to understand the beliefs, attitudes, and practice patterns of providers offering this therapy. The survey was developed and posted on the Nephrology Dialysis Transplantation-Educational (NDT-E) website. Two hundred and seventy-two responses were deemed suitable for complete analysis. It is apparent from the survey that there is great variability in the prevalence of HHD. Physicians have a great deal of interest in this modality, with majority viewing home as being the ideal location for the offer of intensive HD schedules (55%). A significant number (21%) feel intensive HD may be offered even outside the home setting. Those who offer this therapy do not see a financial disadvantage in it. Many units identify lack of appropriately trained personnel (35%) and funding for home adaptation (50.4%) as key barriers to widespread adoption of this therapy. Despite the interest and belief in this therapy among practitioners, HHD therapy is still not within reach of a majority of patients. Modifiable organizational, physician, and patient factors exist, which could potentially redefine the landscape of HHD provision. Well-designed systematic research of national and local barriers is needed to design interventions to help centers facilitate change.

Perceptions and experiences of financial incentives: a qualitative study of dialysis care in England.

OBJECTIVE: The objective of the study was to understand the extent to which financial incentives such as Payment by Results and other payment mechanisms motivate kidney centres in England to change their practices. DESIGN: The study followed a qualitative design. Data collection involved 32 in-depth semistructured interviews with healthcare professionals and managers, focusing on their subjective experience of payment structures. PARTICIPANTS: Participants were kidney healthcare professionals, clinical directors, kidney centre managers and finance managers. Healthcare commissioners from different parts of England were also interviewed. SETTING: Participants worked at five kidney centres from across England. The selection was based on the prevalence of home haemodialysis, ranging from low (<3%), medium (5-8%) and high (>8%) prevalence, with at least one centre in each one of these categories at the time of selection. RESULTS: While the tariff for home haemodialysis is not a clear incentive for its adoption due to uncertainty about operational costs, Commissioning for Quality and Innovation (CQUIN) targets and the Best Practice Tariff for vascular access were seen by our case study centres as a motivator to change practices. CONCLUSIONS: The impact of financial incentives designed at a policy level is influenced by the understanding of cost and benefits at the local operational level. In a situation where costs are unclear, incentives which are based on the improvement of profit margins have a smaller impact than incentives which provide an additional direct payment, even if this extra financial support is relatively small.

Medication burden in CKD-5D: impact of dialysis modality and setting.

BACKGROUND: Medication adherence is thought to be around 50% in the general and dialysis population. Reducing the pill burden (PB) reduces regime complexity and can improve adherence. Increased adherence should lead to improvement in treatment outcomes and patient quality of life. There is currently little published data on PB in CKD-5D across dialysis modalities. METHODS: This is a retrospective, single renal network study. All in-centre HD (MHD), peritoneal dialysis (PD) and home HD (HHD) patients were identified in the Greater Manchester East sector renal network. Information collected included age, sex, comorbidities, daily PB, dialysis vintage and adequacy. Data were retrieved from a customized renal database, clinic and discharge letters with cross validation from the general practitioner when needed. RESULTS: Two hundred and thirty-six prevalent dialysis patients were studied. HHD patients had a significantly lower PB (11 ± 7 pills/day) compared with PD and MHD (16 ± 7 pills/day). The HHD patients required fewer BP medications to meet the recommended target. HD setting was the only significant factor for reducing PB. For home therapies (HHD versus PD), weekly Kt/v and serum phosphate were significant factors influencing PB. When comparing all modalities, OR of PB ≥ 15/day for MHD versus HHD was 3.9 and PD versus HHD was 4.9. The influence of HHD is dominant above factors such as comorbidities or clinical variables in reducing PB for MHD. Higher clearances achieved by HHD could explain differences in PB with PD. CONCLUSION: This is the first comparative study of PB across all dialysis modalities and factors that influence it. The PB advantage in HHD may result in greater adherence and might contribute to the outcome benefit often seen with this modality. Higher clearances achieved by HHD could explain differences in PB with PD but the precise reasons for lower PB remain speculative and deserve further research in larger settings.

Technique survival in home haemodialysis: a composite success rate and its risk predictors in a prospective longitudinal cohort from a tertiary renal network programme.

BACKGROUND: Resurgence of interest in home haemodialysis (HHD) is, in part, due to emerging evidence of the benefits of extended HD regimens, which are most feasibly provided in the home setting. Although specific HHD therapy established at home such as nocturnal HD (NHD) has been reported from individual programmes, little is known about overall HHD success. METHODS: The study included 166 patients who were accepted in the Manchester (UK) HHD training programme through liberal selection criteria. All patients were followed up prospectively until a switch to alternative modality, to include 4528 patient-months of follow-up and about 81 508 HHD sessions during an 8-year period (January 2004-December 2011). Twenty-four patients switched to an alternative modality during the period. Combined technique survival (HHDc) as a composite of training (HHDtr) and at home (HHDhome) was analysed and clinical predictors of HHD modality failure since the commencement of the programme were calculated using Cox regression analysis. Technology-related interruptions to dialysis over a 12-month period and patient-reported reasons for quitting the programme were analysed. RESULTS: Technique survival at 1, 2 and 5 years was 90.2, 87.4, 81.5% (HHDc) and 98.4, 95.4 and 88.9% (HHDhome) when censored for training phase exits, death and transplantation. The combined HHDc modality switch rate is 1 in 192 patient-months of dialysis follow-up. Age >60 years, diabetes, cardiac failure, unit decrease in Hb and increasing score of age-adjusted Charlson--comorbidity index were significantly associated with technique failure. Significant clinical predictors of HHD technique failure in a multivariate model were diabetes (P = 0.002) and cardiac failure (P = 0.05). The majority (61%) switched to an alternative modality for non-medical reasons. The composite of operator error and mechanical breakdown resulting in temporary HHD technique failure was 0.7% per year. CONCLUSIONS: HHD training and technique failure rate are low. Technical errors are infrequent too. Diabetes and cardiac failure are associated with significant risk of technique failure. Although absolute rates are low, training failure is proportionally quite significant, highlighting the importance of reporting the composite technique failure rate (to include early HHD training phase) in HHD programmes.

Barriers to successful implementation of care in home haemodialysis (BASIC-HHD):1. Study design, methods and rationale.

BACKGROUND: Ten years on from the National Institute of Health and Clinical Excellence' technology appraisal guideline on haemodialysis in 2002; the clinical community is yet to rise to the challenge of providing home haemodialysis (HHD) to 10-15% of the dialysis cohort. The renal registry report, suggests underutilization of a treatment type that has had a lot of research interest and several publications worldwide on its apparent benefit for both physical and mental health of patients. An understanding of the drivers to introducing and sustaining the modality, from organizational, economic, clinical and patient perspectives is fundamental to realizing the full benefits of the therapy with the potential to provide evidence base for effective care models. Through the BASIC-HHD study, we seek to understand the clinical, patient and carer related psychosocial, economic and organisational determinants of successful uptake and maintenance of home haemodialysis and thereby, engage all major stakeholders in the process. DESIGN AND METHODS: We have adopted an integrated mixed methodology (convergent, parallel design) for this study. The study arms include a. patient; b. organization; c. carer and d. economic evaluation. The three patient study cohorts (n = 500) include pre-dialysis patients (200), hospital haemodialysis (200) and home haemodialysis patients (100) from geographically distinct NHS sites, across the country and with variable prevalence of home haemodialysis. The pre-dialysis patients will also be prospectively followed up for a period of 12 months from study entry to understand their journey to renal replacement therapy and subsequently, before and after studies will be carried out for a select few who do commence dialysis in the study period. The process will entail quantitative methods and ethnographic interviews of all groups in the study. Data collection will involve clinical and biomarkers, psychosocial quantitative assessments and neuropsychometric tests in patients. Organizational attitudes and dialysis unit practices will be studied together with perceptions of healthcare providers on provision of home HD. Economic evaluation of home and hospital haemodialysis practices will also be undertaken and we will apply scenario ("what … if") analysis using system dynamics modeling to investigate the impact of different policy choices and financial models on dialysis technology adoption, care pathways and costs. Less attention is often given to the patient's carers who provide informal support, often of a complex nature to patients afflicted by chronic ailments such as end stage kidney disease. Engaging the carers is fundamental to realizing the full benefits of a complex, home-based intervention and a qualitative study of the carers will be undertaken to elicit their fears, concerns and perception of home HD before and after patient's commencement of the treatment. The data sets will be analysed independently and the findings will be mixed at the stage of interpretation to form a coherent message that will be informing practice in the future. DISCUSSION: The BASIC-HHD study is designed to assemble pivotal information on dialysis modality choice and uptake, investigating users, care-givers and care delivery processes and study their variation in a multi-layered analytical approach within a single health care system. The study results would define modality specific service and patient pathway redesign. STUDY REGISTRATION: This study has been reviewed and approved by the Greater Manchester West Health Research Authority National Research Ethics Service (NRES) The study is on the NIHR (CLRN) portfolio.

Subcutaneous interstitial pressure and volume characteristics in renal impairment associated with edema.

The kidneys and the interstitial compartment play a vital role in body fluid regulation. The latter may be significantly altered in renal dysfunction, but experimental studies are lacking. To help define this we measured the subcutaneous interstitial pressure, bioimpedance volumes, and edema characteristics in 10 healthy subjects and 21 patients with obvious edema and chronic kidney disease (CKD). Interstitial edema was quantified by the time taken for a medial malleolar thumb pit to refill and termed the edema refill time. Interstitial pressure was significantly raised in CKD compared to healthy subjects. Total body water (TBW), extracellular fluid volume (ECFV), interstitial fluid volume, the ratio of the ECFV to the TBW, and segmental extracellular fluid volume were raised in CKD. The ratio of the ECFV to the TBW and the interstitial fluid volume were the best predictors of interstitial pressure. Significantly higher interstitial pressures were noted in edema of 2 weeks or less duration. A significant nonlinear relationship defined interstitial pressure and interstitial fluid volume. Edema refill time was significantly inversely related to interstitial pressure, interstitial compartment volumes, and edema vintage. Elevated interstitial pressure in CKD with obvious edema is a combined function of accumulated interstitial compartment fluid volumes, edema vintage, and tissue mechanical properties. The edema refill time may represent an important parameter in the clinical assessment of edema, providing additional information about interstitial pathophysiology in patients with CKD and fluid retention.