Patient-reported outcome measures for life participation in peritoneal dialysis: a systematic review.

BACKGROUND: Patients receiving peritoneal dialysis (PD) endure an ongoing regimen of daily fluid exchanges and are at risk of potentially life-threatening complications and debilitating symptoms that can limit their ability to participate in life activities. The aim of the study was to identify the characteristics, content and psychometric properties of measures for life participation used in research in PD. METHODS: We searched MEDLINE, Embase, PsychInfo, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Cochrane Central Register of Controlled Trials from inception to May 2020 for all studies that reported life participation in patients on PD. The characteristics, dimensions of life participation and psychometric properties of these measures were extracted and analyzed. RESULTS: Of the 301 studies included, 17 (6%) were randomized studies and 284 (94%) were nonrandomized studies. Forty-two different measures were used to assess life participation. Of these, 23 (55%) were used in only one study. Fifteen (36%) measures were specifically designed to assess life participation, while 27 (64%) measures assessed broader constructs, such as quality of life, but included questions on life participation. The 36-Item Short Form Health Survey and Kidney Disease Quality of Life Short Form were the most frequently used measures [122 (41%) and 86 (29%) studies, respectively]. Eight (19%) measures had validation data to support their use in patients on PD. CONCLUSIONS: The many measures currently used to assess life participation in patients receiving PD vary in their characteristics, content and validation. Further work to pilot and validate potential measures is required to establish a core patient-reported outcome measure to assess life participation in patients receiving PD.

Importance of Early Inpatient Geriatric Rehabilitation on Outcomes in Individuals on Dialysis.

OBJECTIVE: To report short-term functional outcomes of patients incident to dialysis undergoing inpatient rehabilitation within 3 months of dialysis initiation. DESIGN: Retrospective observation study using prospectively collected data. SETTING: Single-center, hospital-based geriatric dialysis rehabilitation unit. All patients incident to hemodialysis admitted to the geriatric dialysis rehabilitation unit between May 2002 and April 2016 were identified using a retrospective observational design. Clinical and demographic data were collected prospectively and linked, using the unique hospital number and dates of admission and discharge, to FIM scores (used to assess functional recovery) at admission and discharge. PARTICIPANTS: Patients (N=449; mean age ± SD, 74±9y) newly started on hemodialysis (within 3mo). INTERVENTIONS: Inpatient rehabilitation care, short daily dialysis therapy with nephrologist support, and geriatrician assessment. MAIN OUTCOMES: Change in FIM score; discharge location. RESULTS: Patients were admitted within 3 months of hemodialysis initiation. The median length of stay in the rehabilitation program was 43 days (25th and 75th quartile, 33-55 days). Of those with complete data (n=370), 95% had improvement in FIM scores (median changes in total FIM score 25 [quartiles, 16, 33]; in motor FIM 23 [quartiles, 15, 32]; and in cognitive FIM 1 [quartiles, 0, 3], respectively). Most improvement was seen in transfer abilities, grooming, and mobility. A total of 324 patients (72%; 95% CI, 68%-76%) were discharged to a private home. An additional 11 were discharged to a seniors' residence. CONCLUSION: The data suggest that older patients incident to dialysis with functional decline respond well to specialized rehabilitation care and suggest this may be a novel approach to dialysis initiation.

Patient Perspectives on the Meaning and Impact of Fatigue in Hemodialysis: A Systematic Review and Thematic Analysis of Qualitative Studies.

RATIONALE & OBJECTIVE: Fatigue is a highly prevalent and debilitating symptom in patients on hemodialysis therapy due to the uremic milieu, the hemodialysis treatment itself, and other comorbid conditions. However, fatigue remains underrecognized and the consequences are underappreciated because it may not be visible in clinical settings. This study aims to describe the experience that patients undergoing maintenance hemodialysis have with fatigue. STUDY DESIGN: Systematic review and thematic synthesis of qualitative studies. SETTING & STUDY POPULATIONS: Patients undergoing hemodialysis. SEARCH STRATEGY & SOURCES: MEDLINE, Embase, PsycINFO, CINAHL, reference lists, and PhD dissertations were searched from inception to October 2018. DATA EXTRACTION: All text from the results/conclusion of the primary studies. ANALYTICAL APPROACH: Thematic synthesis. RESULTS: 65 studies involving 1,713 participants undergoing hemodialysis were included. We identified 4 themes related to fatigue: debilitating and exhausting burden of dialysis (bodily depletion, trapped in a vicious cycle of postdialysis exhaustion, vigilance and worry inhibiting rest, tiresome and agonizing regimen, and without remedy and relief), restricted life participation (deprived of time, managing energy reserves, frustrating need to rest, and joys foregone), diminishing capacities to fulfil relationship roles (losing ability to work and provide for family, failing as a parent, lacking stamina for sexual intimacy, and relying on others), and vulnerable to misunderstanding (being criticized for the need to rest and failing to meet expectations). LIMITATIONS: Non-English articles were excluded and most studies were conducted in high-income countries. CONCLUSIONS: For patients undergoing hemodialysis who experience fatigue, fatigue is a profound and relentless exhaustion that pervades the entire body and encompasses weakness. The fatigue drains vitality in patients and constrains their ability to do usual activities and fulfill their roles and meet personal aspirations. Explicit recognition of the impact of fatigue and establishing additional effective interventions to improve fatigue are needed.

Cardiologists' and nephrologists' management of atrial fibrillation in hemodialysis patients
.

BACKGROUND: Antithrombotic therapy for stroke prevention in atrial fibrillation (AF) is considered a standard of care, but for hemodialysis (HD) patients the benefits are unclear, and bleeding risks are high. Our study objective was to compare cardiologists' and nephrologists' stroke prevention practices in different patient risk scenarios. MATERIALS AND METHODS: A cross-sectional, online survey was distributed to members of three Canadian physician societies (Nephrology, Cardiovascular, Heart Rhythm), and to cardiologists affiliated with three Canadian Universities. The questionnaire included four AF scenarios in HD patients with varying stroke and bleeding risks. Physicians selected one of six antithrombotic therapy options for each scenario. RESULTS: Cardiologists were 3 times more likely than nephro-logists to choose anticoagulant therapy over both antiplatelet and no drug therapy, regardless of stroke or bleeding risk (p < 0.001). Physicians' drug therapy choices in regards to level of stroke and bleeding risk reflected the expected pattern based on current evidence. CONCLUSION: Cardiologists were more likely to prescribe anticoagulant therapy for AF in the HD population compared to nephrologists, regardless of patient stroke or bleeding risk.

Patient-Reported Outcome Measures for Fatigue in Patients on Hemodialysis: A Systematic Review.

BACKGROUND: Fatigue is a prevalent and debilitating symptom in patients receiving hemodialysis. We aimed to identify and evaluate the characteristics and psychometric properties of patient-reported outcome measures for fatigue in patients receiving hemodialysis, to inform the selection of a robust and feasible measure for use in randomized trials in hemodialysis. STUDY DESIGN: Systematic review of outcome measures for fatigue. SETTING & POPULATION: Patients receiving hemodialysis. SEARCH STRATEGY & SOURCES: MEDLINE, Embase, PsycINFO, and CINAHL from inception to April 2017 were searched for all studies that reported fatigue in patients receiving hemodialysis. ANALYTICAL APPROACH: With a focus on addressing methods, items (individual questions) from all measures were categorized into content and measurement dimensions of fatigue. We assessed the general characteristics (eg, number of items and cost) and psychometric properties of all measures. RESULTS: From 123 studies, we identified 43 different measures: 24 (55%) were developed specifically for the hemodialysis population (of which 18 were nonvalidated author-developed measures for use in their study only), 17 (40%) for other populations, and 2 (5%) for chronic kidney disease (all stages). The measures assessed 11 content dimensions of fatigue, the 3 most frequent being level of energy (19 [44%]), tiredness (15 [35%]), and life participation (14 [33%]); and 4 measurement dimensions: severity (34 [79%]), frequency (10 [23%]), duration (4 [9%]), and change (1 [2%]). The vitality subscale of the 36-Item Short Form Health Survey (SF-36) was the most frequently used (19 [15%] studies), but has only been tested for reliability in hemodialysis. Of the fatigue-specific measures, the Chalder Fatigue Scale was the only one evaluated in hemodialysis, but the full psychometric robustness remains uncertain. LIMITATIONS: For feasibility, we searched for validation studies in the hemodialysis population using the names of measures identified in the primary search strategy. CONCLUSIONS: A very wide range of measures have been used to assess fatigue in patients receiving hemodialysis, each varying in content and length. Many have limited validation data available in this population. A standardized and psychometrically robust measure that captures dimensions of fatigue that are important to patients is needed to estimate and improve this disabling complication of hemodialysis.

Fit for Dialysis: a qualitative exploration of the impact of a research-based film for the promotion of exercise in hemodialysis.

BACKGROUND: Exercise improves functional outcomes and quality of life of older patients with end-stage renal disease undergoing hemodialysis. Yet exercise is not promoted as part of routine care. Health care providers and family carers rarely provide encouragement for patients to exercise, and the majority of older patients remain largely inactive. There is thus the need for a shift in the culture of hemodialysis care towards the promotion of exercise for wellness, including expectations of exercise participation by older patients, and encouragement by health care providers and family carers. Film-based educational initiatives hold promise to effect cultures of best practice, but have yet to be utilized in this population. METHODS: We developed a research-based film, Fit for Dialysis, to promote exercise for wellness in hemodialysis care. Using a qualitative approach, we evaluated the effects that resulted from engagement with this film (e.g. knowledge/attitudes regarding the importance of exercise-based principles of wellness) as well as the generative mechanisms of these effects (e.g. realism, aesthetics). We also explored the factors related to patients, family carers, and health care providers that influenced engagement with the film, and the successful uptake of the key messages of Fit for Dialysis. We conducted qualitative interviews with 10 patients, 10 health care providers, and 10 family carers. Data were analyzed using thematic analysis. RESULTS: The film was perceived to be effective in increasing patients', family carers' and health care providers' understanding of the importance of exercise and its benefits, motivating patients to exercise, and in increasing encouragement by family carers and health care providers of patient exercise. Realism (e.g. character identification) and aesthetic qualities of the film (e.g. dialogue) were identified as central generative mechanisms. CONCLUSIONS: Fit for Dialysis is well-positioned to optimize the health and wellbeing of older adults undergoing hemodialysis. TRIAL REGISTRATION: NCT02754271 ( ClinicalTrials.gov ), retroactively registered on April 21, 2016.

A prospective 2-site parallel intervention trial of a research-based film to increase exercise amongst older hemodialysis patients.

BACKGROUND: Evidence suggests that exercise training for hemodialysis patients positively improves morbidity and mortality outcomes, yet exercise programs remain rare and are not systematically incorporated into care. We developed a research-based film, Fit for Dialysis, designed to introduce, motivate, and sustain exercise for wellness amongst older hemodialysis patients, and exercise counseling and support by nephrologists, nurses, and family caregivers. The objective of this clinical trial is to determine whether and in what ways Fit for Dialysis improves outcomes and influences knowledge/attitudes regarding the importance of exercise for wellness in the context of end-stage renal disease. METHODS/DESIGN: This 2-site parallel intervention trial will recruit 60 older hemodialysis patients from two urban hospitals. The trial will compare the film + a 16-week exercise program in one hospital, with a 16-week exercise-only program in another hospital. Physical fitness and activity measures will be performed at baseline, 8 and 16 weeks, and 12 weeks after the end of the program. These include the 2-min Walk Test, Grip Strength, Duke Activity Status Index, and the Timed Up-and-Go Test, as well as wearing a pedometer for one week. Throughout the 16-week exercise program, and at 12 weeks after, we will record patients' exercise using the Godin Leisure-time Exercise Questionnaire. Patients will also keep a diary of the exercise that they do at home on non-dialysis days. Qualitative interviews, conducted at baseline, 8, and 16 weeks, will explore the impact of Fit for Dialysis on the knowledge/attitudes of patients, family caregivers, and nephrology staff regarding exercise for wellness, and in what ways the film is effective in educating, motivating, or sustaining patient exercise during dialysis, at home, and in the community. DISCUSSION: This research will determine for whom Fit for Dialysis is effective, why, and under what conditions. If Fit for Dialysis is proven beneficial to patients, nephrology staff and family caregivers, research-based film as a model to support exercise promotion and adherence could be used to support the National Kidney Foundation's guideline recommendation (NKF-KDOQI) that exercise be incorporated into the care and treatment of dialysis patients. TRIAL REGISTRATION: NCT02754271 (ClinicalTrials.gov), retroactively registered on April 21, 2016.

Association between depression and mortality in patients receiving long-term dialysis: a systematic review and meta-analysis.

BACKGROUND: We aimed to systematically review and analyze the association between depression and mortality risk in adults with kidney failure treated by long-term dialysis. STUDY DESIGN: A systematic review and meta-analysis of observational studies. SETTING & POPULATION: Patients receiving long-term dialysis. SELECTION CRITERIA FOR STUDIES: Searching MEDLINE, EMBASE, and PsycINFO, we identified studies examining the relationship between depression, measured as depressive symptoms or clinical diagnosis, and mortality. PREDICTOR: Depression status as determined by physician diagnosis or self-reported scales. OUTCOMES: Pooled adjusted HR and OR of depression for all-cause mortality. RESULTS: 15 of 31 included studies showed a significant association between depression and mortality, including 5 of 6 studies with more than 6,000 participants. A significant link was established between the presence of depressive symptoms and mortality (HR, 1.51; 95% CI, 1.35-1.69; I(2)=40%) based on 12 studies reporting depressive symptoms using depression scales (N=21,055; mean age, 57.6 years). After adjusting for potential publication bias, the presence of depressive symptoms remained a significant predictor of mortality (HR, 1.45; 95% CI, 1.27-1.65). In addition, combining across 6 studies reporting per-unit change in depression score (n=7,857) resulted in a significant effect (HR per unit change in score, 1.04; 95% CI, 1.01-1.06; I(2)=74%). LIMITATIONS: Depression or depressive symptoms were documented only from medical charts or a single self-report assessment. Included studies were heterogeneous because of variations in measurement methods, design, and analysis. CONCLUSIONS: There is considerable between-study heterogeneity in reports of depressive symptoms in dialysis patients, likely caused by high variability in the way depressive symptoms are measured. However, the overall significant independent effect of depressive symptoms on survival of dialysis patients warrants studying the underlying mechanisms of this relationship and the potential benefits of interventions to improve depression on the outcomes.

Bone and mineral metabolism and fibroblast growth factor 23 levels after kidney donation.

BACKGROUND: Living kidney donation offers a unique setting to study changes in phosphate and vitamin D homeostasis attributable to mild isolated decreases in estimated glomerular filtration rate (eGFR). STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: 198 living kidney donors and 98 nondonor controls from 9 transplant centers across 3 countries. For donors, median time after donation was 5.3 years. At assessment, donors had a lower eGFR than controls (73 vs 98 mL/min/1.73 m(2)). PREDICTOR: Living kidney donation (mildly decreased eGFR). OUTCOMES: Biochemical markers of chronic kidney disease-mineral and bone disorder. MEASUREMENTS: Serum creatinine, total serum calcium, serum and urine inorganic phosphate, plasma intact parathyroid hormone, serum calcidiol and calcitriol, renal fractional excretion of inorganic phosphate, and intact serum fibroblast growth factor 23 (FGF-23). RESULTS: Serum FGF-23 levels were significantly higher in donors (38.1 vs 29.7 pg/mL; P < 0.001). For every 10-mL/min/1.73 m(2) decrease in eGFR, FGF-23 level was higher by 3.2 (95% CI, 2.0-4.4) pg/mL. Compared with controls, donors showed higher renal tubular fractional excretion of inorganic phosphate (17.8% vs 12.3%; P < 0.001), lower serum phosphate (0.97 vs 1.02 mmol/L; P = 0.03), and lower serum calcitriol values (63 vs 77 pmol/L; P < 0.001). Serum calcium levels were not significantly different between the 2 groups. Plasma intact parathyroid hormone levels were significantly higher in donors (5.7 vs 5.0 pmol/L; P = 0.03), but were not correlated with FGF-23 or calcitriol levels. LIMITATIONS: Enrollment of a small proportion of past donors at participating centers; assessment of only postdonation values; unable to assess seasonal variation or other temporal patterns in biochemical markers; assessment of kidney function was based on eGFR, not measured GFR. CONCLUSIONS: The FGF-23 pathway may be activated in living kidney donors who show early biochemical changes compatible with chronic kidney disease-mineral and bone disorder. Whether these changes influence bone mineral density and fracture rates warrants consideration.

Rehabilitation of the geriatric dialysis patient.

Dialysis is offered to patients with end-stage renal disease as a life-sustaining therapy. However, studies have shown that elderly patients experience high rates of functional disability, hospitalization, institutionalization, and mortality on chronic dialysis therapy, and that the initiation of dialysis is in fact associated with an acceleration in functional decline. These findings have sparked debate about the utility of dialysis for elderly renal patients. In this article, it is proposed that geriatric rehabilitation can prevent, reverse or delay the onset of functional disability and associated adverse outcomes in older dialysis patients, and thus should be incorporated routinely into standard geriatric dialysis care. We outline the causes of disability in elderly dialysis patients, and demonstrate the potential impact of rehabilitation using a case scenario. Models of rehabilitation that have been shown to be effective in improving outcomes for elderly renal and nonrenal populations, including inpatient rehabilitation, exercise training, falls prevention, and home-based models, are reviewed.

Fit for Dialysis: a prospective 2-site parallel intervention trial of a filmed research-based drama to increase exercise amongst older hemodialysis patients.

PURPOSE: The present study aimed to evaluate the impact of a filmed research-based drama-Fit for Dialysis-and an exercise program on patients' physical activity and fitness outcomes. METHODS: Nineteen (10 at the intervention site, 9 at the control site) older patients with a medical diagnosis of hemodialysis-dependent end-stage renal disease were recruited from two acute care hospitals in urban central Canada where they were receiving out-patient hemodialysis care. Participants at the intervention site viewed Fit for Dialysis prior to participating in a 16-week exercise program. Participants at the control site participated only in the 16-week exercise program. Physical activity, measured by total intradialytic exercise time (TIDE), and physical fitness, measured by the Two-Minute Walk Test (2MWT). Secondary measures included: Timed Up and Go (TUG), Grip Strength, Duke Activity Status Index (DASI), Godin Leisure-Time Exerciser Questionnaire (GLTEQ), and pedometer step count. RESULTS: TIDE, TUG, and GLTEQ were better at the intervention site compared to the control site at all time points measured. However, the change over time was not different between the sites. The 2MWT improved over time at the intervention site for those who exercised consistently. No significant differences between sites, or over time were found for any of the other measures. CONCLUSIONS: Further research is needed to determine the effectiveness of this intervention to facilitate the incorporation of exercise into the care and treatment of HD patients.

Geriatric comorbidities, such as falls, confer an independent mortality risk to elderly dialysis patients.

BACKGROUND: As the number of patients aged >/=65 years starting haemodialysis (HD) continues to increase, more patients are at risk of falls, functional decline and cognitive impairment. In an earlier prospective cohort study, we showed that 44% of elderly HD patients had more than one fall within a 1-year period. The objective of this study was to assess whether falls remained predictive of increased mortality risk even after controlling for age, comorbidity, dialysis vintage and laboratory variables. METHODS: Using a prospective, cohort study design, patients aged >/=65 years and on chronic HD during the period April 2002-2003 were recruited. Patients were followed biweekly, and falls occurring within the first year were recorded. Outcome data were collected until death, study end (30 December 2006), transplantation or transfer to another dialysis centre. RESULTS: A total of 162 patients were followed for a median of 32.7 months (quartiles 14-57). In a univariate Cox model with a time-dependent variable for falls status, survival was worse amongst fallers compared to non-fallers (HR 2.13, 95% CI 1.32-3.45; P = 0.002). After adjustment for age, dialysis vintage, comorbidity and laboratory variables, falls were a significant predictor of mortality (HR 1.78, 95% CI 1.07-2.98, P = 0.03). Exclusion of falls associated with concurrent illnesses did not alter the results (HR 1.63, CI 1.02-2.28 P = 0.05). CONCLUSIONS: We conclude that the occurrence of more than one accidental fall in a community-dwelling HD patient aged >/=65 years is associated with an independent increased risk of death. As fall interventions are effective, screening HD patients for falls may be a simple measure of clinical importance.

Persistent peritoneal dialysis catheter exit-site leak in a patient receiving maintenance immunosuppression with sirolimus.

Patients returning to peritoneal dialysis after renal allograft loss are an increasing segment of the end-stage renal disease population. Non-transplant nephrologists will be managing the short- and long-term complications of chronic immunosuppression in these patients. In this case report, the use of sirolimus is described in a patient who developed a significant peritoneal dialysis catheter exit-site leak delaying the initiation of dialysis. The risk of impaired wound healing at the time of peritoneal dialysis catheter implantation must be considered when bridging patients from transplantation to peritoneal dialysis. Particular caution should be paid to the use of sirolimus during this period.

Gastric acid suppression and the risk of enteric peritonitis in peritoneal dialysis patients.

OBJECTIVE: Peritonitis caused by enteric organisms in peritoneal dialysis (PD) patients is associated with greater morbidity and mortality than peritonitis with non-enteric organisms. One reported risk factor for enteric peritonitis (EP) is gastric acid suppression, with two small studies providing conflicting results. The objective of this study was to determine, using a larger patient population, whether gastric acid suppressants are associated with an increased risk of EP. PATIENTS AND METHODS: Using a single-center case-control design, information on episodes of EP occurring between 2003 and 2006 was collected. Control episodes were all non-enteric episodes of peritonitis that occurred during the same time interval. Proton pump inhibitor (PPI) or H(2)-blocker (H(2)B) use prior to development of peritonitis was documented. RESULTS: A total of 228 peritonitis episodes among 137 patients met inclusion criteria. In 32% of episodes, the causative organism was enteric. Gastric acid suppressant use was documented in 46% of episodes, with the majority on PPIs. Overall, gastric acid suppression was not associated with a higher EP risk (p = 0.17). In a post hoc analysis, PPIs were not associated with EP [odds ratio (OR) 1.3, 95% confidence interval (CI) 0.7-2.4; p = 0.42], whereas H(2)Bs were associated with a higher risk of EP (OR 2.9, 95% CI 1.1-7.7; p = 0.04), although the number of patients on H(2)Bs was small. CONCLUSION: Overall, gastric acid suppression was not associated with an increased risk of peritonitis with enteric organisms. While PPI use appears to be safe for PD patients with appropriate indications, the potential risk of EP with H(2)Bs requires further investigation.

Home Palliative Service Utilization and Care Trajectory Among Ontario Residents Dying on Chronic Dialysis.

BACKGROUND: Many patients who receive chronic hemodialysis have a limited life expectancy comparable to that of patients with metastatic cancer. However, patterns of home palliative care use among patients receiving hemodialysis are unknown. OBJECTIVES: We aimed to undertake a current-state analysis to inform measurement and quality improvement in palliative service use in Ontario. METHODS: We conducted a descriptive study of outcomes and home palliative care use by Ontario residents maintained on chronic dialysis using multiple provincial healthcare datasets. The period of study was the final year of life, for those died between January 2010 and December 2014. RESULTS: We identified 9611 patients meeting inclusion criteria. At death, patients were (median [Q1, Q3] or %): 75 (66, 82) years old, on dialysis for 3.0 (1.0-6.0) years, 41% were women, 65% had diabetes, 29.6% had dementia, and 13.9% had high-impact neoplasms, and 19.9% had discontinued dialysis within 30 days of death. During the last year of life, 13.1% received ⩾1 home palliative services. Compared with patients who had no palliative services, those who received home palliative care visits had fewer emergency department and intensive care unit visits in the last 30 days of life, more deaths at home (17.1 vs 1.4%), and a lower frequency of deaths with an associated intensive care unit stay (8.1 vs 37.8%). CONCLUSIONS: Only a small proportion of patients receiving dialysis in Ontario received support through the home palliative care system. There appears to be an opportunity to improve palliative care support in parallel with dialysis care, which may improve patient, family, and health-system outcomes.

CONTEXTE: L'espérance de vie de bon nombre de patients traités par hémodialyse chronique se compare à celle des patients atteints d'un cancer métastatique. Cependant, les tendances d'utilisation des soins palliatifs à domicile chez les patients hémodialysés sont encore peu connues. OBJECTIF DE L'ÉTUDE: Nous souhaitions faire une analyse de l'état actuel des choses afin d'éclairer sur la mesure et l'amélioration de la qualité des soins palliatifs en Ontario. MÉTHODOLOGIE: Nous avons mené une étude descriptive des issues pour les patients et de l'utilisation des soins palliatifs à domicile chez les patients hémodialysés en Ontario. Plusieurs ensembles de données provinciales en soins de santé ont été employés pour procéder à l'analyse. La dernière année de vie des patients décédés entre janvier 2010 et décembre 2014 a constitué la période étudiée. RÉSULTATS: Les patients satisfaisant les critères d'inclusion étaient au nombre de 9 611. La cohorte était constituée à 41 % de femmes. Au moment du décès, l'âge médian (Q1; Q3) des patients était de 75 ans (66; 82 ans) et la médiane de la durée des traitements d'hémodialyse était de trois ans en moyenne (1,0; 6,0 ans). Parmi les comorbidités recensées au décès, 65 % des patients étaient aussi diabétiques, environ un tiers (29,3 %) étaient atteints de démence et 13,9 % présentaient des néoplasmes. Dans les 30 jours précédant leur décès, 19,9 % des patients avaient cessé leurs traitements de dialyse. Au cours de la dernière année de vie, seulement 13,1 % des patients de la cohorte avaient reçu au moins un service de soins palliatifs à domicile. Lorsque comparés aux patients n'ayant reçu aucun service en soins palliatifs, ils se sont moins souvent présentés aux urgences et ont moins souvent séjourné dans les unités de soins intensifs. De plus, une plus grande proportion des patients ayant reçu des soins palliatifs sont décédés à domicile, soit 17,1 % contre 1,4 % des patients n'ayant reçu aucun service en soins palliatifs. Enfin, le taux de mortalité associé à un séjour aux soins intensifs s'est avéré bien inférieur chez les patients qui avaient reçu des soins palliatifs, soit 8,1 % contre 37,8 % pour les patients n'ayant reçu aucun service de soins palliatifs. CONCLUSION: En Ontario, une très faible proportion des patients hémodialysés a reçu du soutien par l'entremise du système de soins palliatifs à domicile au cours de la période étudiée. Il semble donc y avoir une possibilité d'améliorer l'offre de soins palliatifs parallèlement aux traitements de dialyse; et ceci pourrait avoir une incidence positive sur les patients et leurs proches, de même que sur le système de santé.

Changes in survival among elderly patients initiating dialysis from 1990 to 1999.

BACKGROUND: Over the past decade, there has been a steep rise in the number of people with complex medical problems who require dialysis. We sought to determine the life expectancy of elderly patients after starting dialysis and to identify changes in survival rates over time. METHODS: All patients aged 65 years or older who began dialysis in Canada between 1990 and 1999 were identified from the Canadian Organ Replacement Register. We used Cox proportional hazards models to examine the effect that the period during which dialysis was initiated (era 1, 1990-1994; era 2, 1995-1999) had on patient survival, after adjusting for diabetes, sex and comorbidity. Patients were followed from initiation of dialysis until death, transplantation, loss to follow-up or study end (Dec. 31, 2004). RESULTS: A total of 14,512 patients aged 65 years or older started dialysis between 1990 and 1999. The proportion of these patients who were 75 years or older at the start of dialysis increased from 32.7% in era 1 (1990-1994) to 40.0% in era 2 (1995-1999). Despite increased comorbidity over the 2 study periods, the unadjusted 1-, 3- and 5-year survival rates among patients aged 65-74 years at dialysis initiation rose from 74.4%, 44.9% and 25.8% in era 1 to 78.1%, 51.5% and 33.5% in era 2. The respective survival rates among those aged 75 or more at dialysis initiation increased from 67.2%, 32.3% and 14.2% in era 1 to 69.0%, 36.7% and 20.3% in era 2. This survival advantage persisted after adjustment for diabetes, sex and comorbidity in both age groups (65-74 years: hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.72- 0.81; 75 years or more: HR 0.86, 95% CI 0.80-0.92). INTERPRETATION: Survival after dialysis initiation among elderly patients has improved from 1990 to 1999, despite an increasing burden of comorbidity. Physicians may find these data useful when discussing prognosis with elderly patients who are initiating dialysis.

Clinical outcomes of elderly patients undergoing chronic peritoneal dialysis: experiences from one center and a review of the literature.

OBJECTIVES: The purpose of this study was to evaluate the outcome and to identify predictors of mortality in elderly patients on chronic peritoneal dialysis (CPD). METHODS: We retrospectively reviewed the charts of patients who started on CPD at the Division of Nephrology, University Health Network (UHN), Toronto, from 1 January 1994 to 31 December 2001. Patients were divided into three different age groups (/=75 years). Baseline variables included demographics, information on primary kidney disease, comorbidities when dialysis was first started, and initial biochemical data such as serum albumin, serum calcium (corrected for protein), phosphate, hemoglobin (Hb), total cholesterol, and triglyceride. The effects of these variables on survival were studied using a univariate procedure and then analyzed using multivariate Cox proportional hazards models in order to evaluate their independent relation to mortality. RESULTS: This study included 358 patients, among whom 213 (59.5%) were /=75 years old. Mean actuarial (death-censored) technique survival for the overall study population was 72.4 months (95% confidence interval [CI]: 66.3-78.5); in the /=75 year-old groups mean survivals were 74.4, 62.0, and 64.5 months, respectively. The death-censored technique survival for the elderly patients was not statistically significantly different from that in young patients (P = 0.778). In the overall study population, the mean patient survival was 70.4 months (95% CI 64.2-76.6), while the mean survivals for the /=75 year-old groups were 82.3, 54.0, and 50.0 months, respectively. The overall survival rates at 12 months were 98%, 84%, and 85% for the /=75 year-old groups, respectively. Not surprisingly, the survival of elderly patients on CPD is shorter than that of younger patients (P = 0.000). There were no significant differences between the two elderly groups (P = 0.439). Mortality was predicted by lower initial serum total cholesterol and albumin as well as higher serum calcium levels. CONCLUSION: Our study shows that elderly patients starting CPD had a death-censored technique survival comparable to that of younger patients. As expected, the survival of elderly patients on CPD was shorter than the survival of younger patients. Lower initial serum total cholesterol and albumin as well as higher initial serum calcium were associated with mortality in the elderly population. Our findings indicate that chronic peritoneal dialysis is a successful dialysis option for elderly patients with end stage renal disease. Measures to improve their nutritional state and achieve normalization of serum calcium might improve their survival.