Availability and Quality of Dialysis Care in Rural versus Urban US Counties.

INTRODUCTION: Rural areas face significant disparities in dialysis care compared to urban areas due to limited access to dialysis facilities, longer travel distances, and a shortage of healthcare professionals. The objective of this study was to conduct a national examination of rural-urban differences in quality of dialysis care offered across counties in the USA. METHODS: Data were gathered from Medicare-certified dialysis facilities in 2020 from the Centers for Medicare and Medicaid Services website. To identify high-need counties, county-level estimated crude prevalence of diabetes in adults was obtained from the 2022 CDC PLACES data portal. Our analysis reviewed 3,141 counties in the USA. The primary outcome measured was whether the county had a dialysis facility. Among those counties that had a dialysis facility, additional outcomes were the average star rating, whether peritoneal dialysis was offered, and whether home dialysis was offered. RESULTS: The type of services offered by dialysis facilities varied significantly, with peritoneal dialysis being the most commonly offered service (50.8%), followed by home hemodialysis (28.5%) and late-shift services (16.0%). These service availabilities are more prevalent in urban facilities than in rural facilities. The Centers for Medicare and Medicaid Services Five Star Quality ratings were quite different between urban and rural facilities, with 40.4% of rural facilities having a ranking of five, compared to 27.1% in urban. CONCLUSION: The majority of rural counties lack a single dialysis facility. Counties with high rates of chronic kidney disease, diabetes, and blood pressure, deemed high need, were less likely to have a highly rated dialysis facility. The findings can be used to further inform targeted efforts to increase diabetes educational programming and design appropriate interventions to those residing in rural communities and high-need counties who may need it the most.

Comparing Mortality of Peritoneal and Hemodialysis Patients in an Era of Medicare Payment Reform.

BACKGROUND: Prior studies have shown peritoneal dialysis (PD) patients to have lower or equivalent mortality to patients who receive in-center hemodialysis (HD). Medicare's 2011 bundled dialysis prospective payment system encouraged expansion of home-based PD with unclear impacts on patient outcomes. This paper revisits the comparative risk of mortality between HD and PD among patients with incident end-stage kidney disease initiating dialysis in 2006-2013. RESEARCH DESIGN: We conducted a retrospective cohort study comparing 2-year all-cause mortality among patients with incident end-stage kidney disease initiating dialysis via HD and PD in 2006-2013, using data from the US Renal Data System and Medicare. Analysis was conducted using Cox proportional hazards models fit with inverse probability of treatment weighting that adjusted for measured patient demographic and clinical characteristics and dialysis market characteristics. RESULTS: Of the 449,652 patients starting dialysis between 2006 and 2013, the rate of PD use in the first 90 days increased from 9.3% of incident patients in 2006 to 14.2% in 2013. Crude 2-year mortality was 27.6% for patients dialyzing via HD and 16.7% for patients on PD. In adjusted models, there was no evidence of mortality differences between PD and HD before and after bundled payment (hazard ratio, 0.96; 95% confidence interval, 0.89-1.04; P=0.33). CONCLUSIONS: Overall mortality for HD and PD use was similar and mortality differences between modalities did not change before versus after the 2011 Medicare dialysis bundled payment, suggesting that increased use of home-based PD did not adversely impact patient outcomes.

The Current Status and Future of Peritoneal Dialysis in Japan.

BACKGROUND: Recent reports have outlined the present conditions and future prospects of Japanese patients on dialysis. Japan currently has the most rapidly aging population in the world and its dialysis population is also aging rapidly. SUMMARY: Patients on dialysis in Japan have an extremely good prognosis, probably because of the national health insurance system with efficient introduction of patients to dialysis, creation of a good arteriovenous shunt, an adequate patient education system, management by skilled medical, nursing, and technical staff, and good hygiene. However, although many patients are receiving hemodialysis in Japanese facilities, fewer patients are receiving peritoneal dialysis (PD) or undergoing transplantation. PD is home based, and so offers a high degree of freedom and patient satisfaction, particularly for the elderly. The government is aware of the progress made in the fields of PD and transplantation, and in 2018 revised the reimbursement policy for fees for medical service in accordance with the goal of implementing an "integrated community-based health care system." Key Message: PD is an option for elderly patients and should be considered a strategy for management of renal disease in Japan's super-aging society.

[10 years of external quality assurance in dialysis in Germany: Results and future prospects]. / 10 Jahre Qualitätssicherung Dialyse in Deutschland ­ Bilanz und Ausblick.

BACKGROUND: In 2006, the Federal Joint Committee introduced a quality assurance programme for ambulatory dialysis treatment in Germany. Regarding the impact of chronic dialysis treatment on the quality of life of patients and on health care costs, quality assurance in dialysis is considered highly relevant. The directive on Quality Assurance in Dialysis (QSD-RL) established an external quality assurance programme on the basis of the assessment of certain quality parameters combined with an internal quality management system based on benchmarking parameters in all dialysis practices and centres. Data on quality parameters are collected and analysed quarterly. Regional associations of statutory health insurance physicians take responsibility for quality improvement measures and sanctions. This article aims to provide an overview of the development of quality parameters from 2008 to 2015. METHODS: We analysed the summarised annual quality reports published on the website of the Federal Joint Committee between 2009 and 2016. We present results on the so-called core quality parameters duration and frequency of dialysis sessions (both for haemodialysis patients), wKt/V for peritoneal dialysis patients, and percentage of haemodialysis patients with central venous catheters which has only been measured since 2014. RESULTS AND CONCLUSIONS: In 2015, 92,000 patients received outpatient dialysis. Between 2008 and 2015, the results for the core quality parameters duration and frequency of haemodialysis improved while the results for wKt/V seemingly show an unfavourable trend. The percentage of patients with central venous catheters appears to be quite high, and thus indicates that there is potential for quality improvement. FUTURE PERSPECTIVES: For the future, the Federal Joint Committee has resolved to merge the quality assurance programmes in dialysis and in kidney transplantation into a newly designed programme that has the potential to follow patients through all stages and kinds of renal replacement therapy and to focus on further aspects of treatment quality.

PD First Policy: Thailand's Response to the Challenge of Meeting the Needs of Patients With End-Stage Renal Disease.

Providing dialysis for end-stage kidney disease (ESKD) patients nationwide in a developing country such as Thailand is challenging. Even after roll-out of the Thai Universal Coverage Scheme in 2002, treatment for ESKD was not covered and patients struggled to afford dialysis. There was an urgent need to improve financial risk protection for patients with ESKD. Advocacy by nephrologists, health economists, and civil society seeking equity in access to dialysis, and responsiveness from policy makers, led to the methodical development of the Peritoneal Dialysis (PD) First policy and marked a turning point in ESKD care in Thailand. Despite the obvious economic concerns and the prevailing popularity of hemodialysis the policy has been strategically and successfully implemented since 2008. The Thai PD First policy has saved the lives of nearly 50,000 ESKD patients being dialyzed under the universal coverage scheme. Despite ongoing challenges the program continues to evolve. This article summarizes the key strategies underlying the policy development and implementation, the integration of home-based dialysis into the well-established Thai health care system, the use of the Chronic Care Model concept in PD care, and the impact of choosing PD as the first choice of dialysis therapy, which has slowed the growth of dialysis costs.

Peritoneal Dialysis Treatment Modality Option in Acute Kidney Injury.

BACKGROUND: Peritoneal dialysis (PD) may be a feasible and safe alternative to haemodialysis not only in the chronic but also in the acute setting. It was previously widely accepted as a modality for acute kidney injury (AKI) treatment, but its practice declined in favor of other types of extracorporeal therapies. SUMMARY: The interest in PD to manage AKI patients has been increased and PD is now frequently used in developing countries because of its lower cost and minimal infrastructural requirements. Studies from these countries have shown that, with careful thought and planning, critically ill patients can be successfully treated using PD. Some of the classic limitations of PD use in AKI, such as infectious and mechanical complications and poor metabolic control, have been decreased with the use of cyclers, flexible catheters, and a high volume of dialysate. The recent publication of the International Society of Peritoneal Dialysis guidelines for PD in AKI has tried to address these issues and provide an evidence-based standard by which to initiate therapy. Key Message: In this review, advances in technical aspects and the advantages and limitations of PD were discussed; it clearly showed that PD is a simple, safe, and efficient way to correct metabolic, electrolyte, acid - base, and volume disturbances generated by AKI and it can be used as a renal replacement therapy modality to treat AKI, both in and out of the intensive care unit setting.

A contemporary approach to the prevention of peritoneal dialysis-related peritonitis in children: the role of improvement science.

Peritonitis is a leading cause of hospitalizations, morbidity, and modality change in pediatric chronic peritoneal dialysis (CPD) patients. Despite guidelines published by the International Society for Peritoneal Dialysis aimed at reducing the risk of peritonitis, registry data have revealed significant variability in peritonitis rates among centers caring for children on CPD, which suggests variability in practice. Improvement science methods have been used to reduce a variety of healthcare-associated infections and are also being applied successfully to decrease rates of peritonitis in children. A successful quality improvement program with the goal of decreasing peritonitis will not only include primary drivers directly linked to the outcome of peritonitis, but will also direct attention to secondary drivers that are important for the achievement of primary drivers, such as health literacy and patient and family engagement strategies. In this review, we describe a comprehensive improvement science model for the reduction of peritonitis in pediatric patients on CPD.

A cost-effective method to get insight into the peritoneal dialysate effluent proteome.

Protein depletion with acetonitrile and protein equalization with dithiothreitol have been assessed with success as proteomics tools for getting insight into the peritoneal dialysate effluent proteome. The methods proposed are cost-effective, fast and easy of handling, and they match the criteria of analytical minimalism: low sample volume and low reagent consumption. Using two-dimensional gel electrophoresis and peptide mass fingerprinting, a total of 72 unique proteins were identified. Acetonitrile depletes de PDE proteome from high-abundance proteins, such as albumin, and enriches the sample in apolipo-like proteins. Dithiothreitol equalizes the PDE proteome by diminishing the levels of albumin and enriching the extract in immunoglobulin-like proteins. The annotation per gene ontology term reveals the same biological paths being affected for patients undergoing peritoneal dialysis, namely that the largest number of proteins lost through peritoneal dialysate are extracellular proteins involved in regulation processes through binding. SIGNIFICANCE: Renal failure is a growing problem worldwide, and particularly in Europe where the population is getting older. Up-to-date there is a focus of interest in peritoneal dialysis (PD), as it provides a better quality of life and autonomy of the patients than other renal replacement therapies such as haemodialysis. However, PD can only be used during a short period of years, as the peritoneum lost its permeability through time. Therefore to make a breakthrough in PD and consequently contribute to better healthcare system it is urgent to find a group of biomarkers of peritoneum degradation. Here we report on two cost-effective methods for protein depletion in peritoneal dialysate effluent (PDE). The use of ACN and DTT over PDE to deplete high abundant proteins or to equalize the concentration of proteins, respectively, performs well and with similar protein profiles than when the same chemicals are used in human plasma samples. ACN depletes de PDE proteome from large proteins, such as albumin, and enriches the sample in apolipoproteins. DTT equalizes the PDE proteome by diminishing the levels of large proteins such as albumin and enriching the extract in immunoglobulins. Although the number and type of proteins identified are different, the annotation per gene ontology term reveals the same biological paths being affected for patients undergoing peritoneal dialysate. Thus, the largest number of proteins lost through peritoneal dialysate belongs to the group of extracellular proteins involved in regulation processes through binding. As for the searching of biomarkers, DTT seems to be the most promising of the two methods because acts as an equalizer and it allows interrogating more proteins in the same sample.

ISPD Cardiovascular and Metabolic Guidelines in Adult Peritoneal Dialysis Patients Part I - Assessment and Management of Various Cardiovascular Risk Factors.

Cardiovascular disease contributes significantly to the adverse clinical outcomes of peritoneal dialysis (PD) patients. Numerous cardiovascular risk factors play important roles in the development of various cardiovascular complications. Of these, loss of residual renal function is regarded as one of the key cardiovascular risk factors and is associated with an increased mortality and cardiovascular death. It is also recognized that PD solutions may incur significant adverse metabolic effects in PD patients. The International Society for Peritoneal Dialysis (ISPD) commissioned a global workgroup in 2012 to formulate a series of recommendations regarding lifestyle modification, assessment and management of various cardiovascular risk factors, as well as management of the various cardiovascular complications including coronary artery disease, heart failure, arrhythmia (specifically atrial fibrillation), cerebrovascular disease, peripheral arterial disease and sudden cardiac death, to be published in 2 guideline documents. This publication forms the first part of the guideline documents and includes recommendations on assessment and management of various cardiovascular risk factors. The documents are intended to serve as a global clinical practice guideline for clinicians who look after PD patients. The ISPD workgroup also identifies areas where evidence is lacking and further research is needed.

Substitute treatment and replacement in chronic kidney disease: peritoneal dialysis, hemodialysis and transplant.

Chronic dialysis replacement treatments or renal transplants are instituted when the patient's glomerular filtration rate, measured by 24-h urine endogenous creatinine clearance, is <10-15 ml/mm and, as the The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI), European and Canadian guidelines point out, when one or two of the following complications occur: "uremic toxicity" symptoms, significant fluid retention that does not respond to loop diuretics, hyperkalemia, chronic anemia (hemoglobin <8 g), metabolic acidosis or acute pulmonary edema. In all patients for whom transplant is indicated, a selected live donor must be sought or, in the absence of contraindications, the patient should be registered with the national cadaver donation waiting list. While waiting for the transplant, patients will be on a chronic dialysis program. There is no national registry of patients undergoing chronic dialysis; only indirect data from the Mexican Kidney Foundation and the dialysis industry are available. However, it is estimated that 40,000-50,000 people are under this treatment and the numbers grow by 11% every year. Overall, it is thought that for every patient receiving chronic dialysis, there is one more patient who dies without access to therapy. Hemodialysis units must comply with the Official Hemodialysis Standard and the General Health Council Hemodialysis Unit Quality Assessment Form.

Tratamientos sustitutivos en enfermedad renal: diálisis peritoneal, hemodiálisis y trasplante renal / Substitute treatment and replacement in chronic kidney disease: peritoneal dialysis, hemodialysis and transplant

Los tratamientos sustitutivos de diálisis crónica o trasplante renal se inician cuando la filtración glomerular del paciente medida por la depuración de creatinina endógena en la orina de 24 horas es inferior a 15 o 10 ml/mm y cuando se presentan complicaciones. A los enfermos con indicaciones de trasplante se les debe buscar un donador vivo seleccionado o inscribirlos en la lista de espera nacional de donación cadavérica si no existen contraindicaciones. Aun cuando no hay un registro nacional mexicano de pacientes en diálisis crónica, solo datos indirectos de la Fundación Mexicana del Riñón y de la industria de diálisis, se estima que de 40 mil a 50 mil son sujetos a este tratamiento y que anualmente la cifra se incrementa 11 %. En términos generales se considera que por cada enfermo en diálisis crónica hay otro que fallece sin acceso al tratamiento. Las unidades de hemodiálisis deben cumplir con la norma oficialmexicana de hemodiálisis y la cédula de evaluación de la calidad de las unidades de hemodiálisis del Consejo de Salubridad General. Es aconsejable que los pacientes sean incorporados a diálisis crónica después de ser presentados al comité de diálisis, y que el tratamiento se aplique con la aceptación del enfermo o sus familiares y se registre en el censo nominal.

Chronic dialysis replacement treatments or renal transplants are instituted when the patient's glomerular filtration rate, measured by 24-h urine endogenous creatinine clearance, is <10-15 ml/mm and, as the The National Kidney Foundation Kidney Disease Outcomes Quality Initiative (NKF KDOQI), European and Canadian guidelines point out, when one or two of the following complications occur: "uremic toxicity" symptoms, significant fluid retention that does not respond to loop diuretics, hyperkalemia, chronic anemia (hemoglobin <8 g), metabolic acidosis or acute pulmonary edema. In all patients for whom transplant is indicated, a selected live donor must be sought or, in the absence of contraindications, the patient should be registered with the national cadaver donation waiting list. While waiting for the transplant, patients will be on a chronic dialysis program. There is no national registry of patients undergoing chronic dialysis; only indirect data from the Mexican Kidney Foundation and the dialysis industry are available. However, it is estimated that 40,000-50,000 people are under this treatment and the numbers grow by 11% every year. Overall, it is thought that for every patient receiving chronic dialysis, there is one more patient who dies without access to therapy. Hemodialysis units must comply with the Official Hemodialysis Standard and the General Health Council Hemodialysis Unit Quality Assessment Form.

[An assessment approach to the adequacy of peritoneal dialysis based on modified MART2 network].

Against the large number of assessment indices to the adequacy peritoneal dialysis and incompatibility of some indices, an intelligent assessment approach to the peritoneal dialysis adequacy based on MART2 (modified from ART2) network is proposed. After non-dimension and weighting preconditioning, the assessment indices were put to MART2 and sorted into many clusters. The center-of-gravity of each cluster was identified as adequacy or inadequacy according to the assessment criteria of dialysis adequacy, and the adequacy of each cluster could be determined by the adequacy of corresponding center-of-gravity when the network threshold was high. Finally, the peritoneal dialysis adequacy of each patient could be judged according to the adequacy of cluster to which the patients' indices belong. Experimental results demounstrate its effectiveness.

Two-year experience with telemedicine in the follow-up of patients in home peritoneal dialysis.

We evaluated the use of telemedicine in the long-term control of stable patients undergoing peritoneal dialysis at home. From September 2003 to August 2005, patients were randomly selected from current cases and invited to join study group A, in which they had telemedicine support. Patients not selected for this group, or who refused the invitation, were placed in study group B, and used for comparison. There were 25 patients in group A and 32 patients in group B. Videoconferencing equipment was installed in each patient's home, connected to a videoconferencing unit at the hospital by three ISDN lines. Patients in group A were followed for a mean of 8 months (range 3-24) with alternate months of teleconsultations and hospital visits. A total of 172 teleconsultations were conducted. A mean of 22 min (SD 9) were spent on each teleconsultation, significantly less than in hospital consultations, which took a mean of 33 min (SD 8) (P<0.01). In 148 teleconsultations (89%) medical treatment was modified. In 4 cases (2%) patients needed a hospital visit. In all instances (100%) the condition of the catheter exit site and the presence of oedema could be evaluated. In group A, the estimated cost of telemedicine was euro198 and that of a hospital visit was euro177. The mean hospitalization rate was 2.2 days/patient/year in group A and 5.7 days/patient/year in group B (P<0.05). Home telemedicine appears to be clinically useful in the long-term follow-up of stable patients undergoing peritoneal dialysis, and the costs and savings also seem to be encouraging.

Establishing a successful home dialysis program.

The renewed interest in home dialysis therapies makes it pertinent to address the essentials of establishing and running a successful home dialysis program. The success of a home program depends on a clear understanding of the structure of the home program team, the physical plant, educational tool requirements, reimbursement sources and a business plan. A good command of the technical and economic aspects is important, but the primary drivers for the creation and growth of a home dialysis program are the confidence and commitment of the nephrological team.

Patients' experiences of dialysis services: are national health strategy targets being met?

BACKGROUND: The National Health Strategy envisages a health system incorporating patient views; and providing accessible, consultant-led dialysis services with patient choice of dialysis modality, in all regions. AIMS: To describe patients' experiences of renal services against National Health Strategy objectives. METHODS: Telephone interviews with 192 dialysis patients from three hospitals in the Eastern region. RESULTS: One-quarter of participants (16% of haemodialysis [HD] and 46% of peritoneal dialysis patients) lived outside the Eastern region, and travelled there because dialysis was not available locally. Two-thirds (65%) had a choice of dialysis modality. High satisfaction with interpersonal care was observed (83-98% satisfaction). Dissatisfaction with physical environment included parking (39-56%), waiting areas (62-69%), HD unit space (74%). Regarding support services, dietary services were satisfactory (92-95%), with lower satisfaction ratings for social and financial support services (62%). CONCLUSIONS: Structural and management issues must be addressed to advance a quality agenda for renal care in Ireland.

Integrated end-stage renal disease care: the role of peritoneal dialysis.

This paper reviews the rationale behind the proposed policy of using peritoneal dialysis (PD) as the initial treatment modality in patients with end-stage renal disease (ESRD). The better preservation of residual renal function associated with PD is emphasized along with its potential cardiovascular benefits. The superior patient survival on PD, relative to hemodialysis, during the first 2 years on dialysis in both the United States and Canada is discussed, as are the potential advantages of PD in terms of hepatitis C prevention, anaemia management and quality of life. The lower cost of PD in association with these clinical advantages lead to the modality being more cost-effective in the early years on dialysis. The relatively high technique failure rate on PD, however, subsequently leads to an increasing need for haemodialysis. A policy of integrated dialysis care with PD first and then haemodialysis, as required, is advocated as a more cost-effective approach to ESRD in suitable patients.

Patient assessment of quality of care in a chronic peritoneal dialysis facility.

The percentage of patients with end-stage renal disease (ESRD) maintained on chronic peritoneal dialysis (CPD) in the United States remains well less than the percentage in several other countries. Furthermore, there has recently been a decline in the percentage of patients with ESRD in the United States undergoing CPD. The reasons for this decline are uncertain, and investigators have implicated problems with the kinetics of peritoneal dialysis, peritonitis and exit-site infections, and psychosocial stresses imposed by the therapy. Few studies, however, have considered the role of the dialysis facility itself and patient perceptions of the facility as contributing to problems with the long-term acceptance of CPD. This study is designed to examine patients' perceptions of the organization and structure of the peritoneal dialysis facility and their interactions with the facility, focusing attention on areas of patient satisfaction and dissatisfaction with the facility. The study was conducted in a large, freestanding peritoneal dialysis program in an urban area that currently treats 140 patients undergoing CPD. Thirty patients were randomly selected to participate in the present study. A structured interview that included open-ended questions was administered and tape-recorded by a trained interviewer not affiliated with the dialysis unit. Patient responses were then reviewed by two investigators, and a taxonomy of patient satisfaction and dissatisfaction was developed, using a modification of the classification proposed by Concato and Feinstein. Patient responses were then categorized according to the taxonomy. The most frequently cited areas of patient satisfaction included the amount of information and instruction provided by the staff (n = 30), personal atmosphere of the facility (n = 30), efficiency of delivery of the dialysis supplies (n = 23), and availability of the primary nurse (n = 18). The importance of the nurse-patient interaction was emphasized by all 30 patients, whereas the physician-patient interaction was cited by only 14 patients. The most frequently cited area of dissatisfaction noted by all 30 patients concerned the dialysis regimen itself. The present study focuses attention on patient perceptions of their CPD facility, identifying areas of satisfaction and dissatisfaction. The analysis is important not only in providing a framework for CPD facilities with which to review their own interactions with CPD patients, but also for identifying those areas that require attention to maintain the long-term viability of CPD therapy.