COVID-19 in patients undergoing long-term dialysis in Ontario.

BACKGROUND: Patients undergoing long-term dialysis may be at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and of associated disease and mortality. We aimed to describe the incidence, risk factors and outcomes for infection in these patients in Ontario, Canada. METHODS: We used linked data sets to compare disease characteristics and mortality between patients receiving long-term dialysis in Ontario who were diagnosed SARS-CoV-2 positive and those who did not acquire SARS-CoV-2 infection, between Mar. 12 and Aug. 20, 2020. We collected data on SARS-CoV-2 infection prospectively. We evaluated risk factors for infection and death using multivariable logistic regression analyses. RESULTS: During the study period, 187 (1.5%) of 12 501 patients undergoing dialysis were diagnosed with SARS-CoV-2 infection. Of those with SARS-CoV-2 infection, 117 (62.6%) were admitted to hospital and the case fatality rate was 28.3%. Significant predictors of infection included in-centre hemodialysis versus home dialysis (odds ratio [OR] 2.54, 95% confidence interval [CI] 1.59-4.05), living in a long-term care residence (OR 7.67, 95% CI 5.30-11.11), living in the Greater Toronto Area (OR 3.27, 95% CI 2.21-4.80), Black ethnicity (OR 3.05, 95% CI 1.95-4.77), Indian subcontinent ethnicity (OR 1.70, 95% CI 1.02-2.81), other non-White ethnicities (OR 2.03, 95% CI 1.38-2.97) and lower income quintiles (OR 1.82, 95% CI 1.15-2.89). INTERPRETATION: Patients undergoing long-term dialysis are at increased risk of SARS-CoV-2 infection and death from coronavirus disease 2019. Special attention should be paid to addressing risk factors for infection, and these patients should be prioritized for vaccination.

Bundled Payment Reform and Dialysis Facility Closures in ESKD.

BACKGROUND: In 2011, inclusion of injectable medications into an expanded ESKD payment bundle prompted concerns that dialysis facilities facing higher costs might close, disrupting care delivery and access to care. Whether this policy change influenced dialysis facility closures is unknown. METHODS: To examine whether facility closures increased after 2011 and whether factors influencing closures changed, we analyzed US Renal Data System registry data to identify all patients receiving in-center hemodialysis from 2006 through 2015 and to track dialysis facility closures. We used interrupted time series logistic regression models and estimated marginal effects to examine immediate and longer-term changes in the likelihood of being affected by facility closures following payment reform. We also examined whether associations between selected predictors of closures indicating populations at "high risk" of closure (patient characteristics, facility characteristics, and geography-related characteristics) and closures changed after payment reform. RESULTS: Dialysis facility closures were uncommon over the study period. In adjusted models, the relative odds of experiencing a closure declined by 37% (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.59 to 0.67) immediately after payment reform and declined by an additional 6% (OR, 0.94; 95% CI, 0.91 to 0.97) annually thereafter, corresponding to a 0.3% lower absolute probability of closure in 2015 in association with payment reform. Patients who were black and who dialyzed at small, hospital-based facilities experienced slight increases in closures following payment reform, whereas Hispanic and Medicare/Medicaid dual-eligible patients experienced slight decreases in closures. CONCLUSIONS: Expansion of the ESKD payment bundle was not associated with increased closure of dialysis facilities, although the likelihood of closures changed slightly for some higher-risk populations.

Arteriovenous Fistula Use in the United States and Dialysis Facility-Level Comorbidity Burden.

RATIONALE & OBJECTIVE: Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities. PREDICTORS: Facility-level burden of patient comorbid conditions; patient characteristics. OUTCOMES: Odds of AVFs versus other access types; facility-level use of AVFs. ANALYTICAL APPROACH: Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility. RESULTS: Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than 99th percentile of comorbidity burden had AVF use that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile of comorbidity burden had AVF use that was 2.64 percentage points greater than the median. LIMITATIONS: Limited to Medicare dialysis-dependent patients treated for 1 year or more. CONCLUSIONS: After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively high patient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens.

COVID-19 Outbreak in an Urban Hemodialysis Unit.

RATIONALE & OBJECTIVE: Hemodialysis patients are at increased risk for coronavirus disease 2019 (COVID-19) transmission due in part to difficulty maintaining physical distancing. Our hemodialysis unit experienced a COVID-19 outbreak despite following symptom-based screening guidelines. We describe the course of the COVID-19 outbreak and the infection control measures taken for mitigation. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: 237 maintenance hemodialysis patients and 93 hemodialysis staff at a single hemodialysis center in Toronto, Canada. EXPOSURE: Universal screening of patients and staff for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). OUTCOMES: The primary outcome was detection of SARS-CoV-2 in nasopharyngeal samples from patients and staff using reverse transcriptase-polymerase chain reaction (RT-PCR). ANALYTICAL APPROACH: Descriptive statistics were used for clinical characteristics and the primary outcome. RESULTS: 11 of 237 (4.6%) hemodialysis patients and 11 of 93 (12%) staff members had a positive RT-PCR test result for SARS-CoV-2. Among individuals testing positive, 12 of 22 (55%) were asymptomatic at time of testing and 7 of 22 (32%) were asymptomatic for the duration of follow-up. One patient was hospitalized at the time of SARS-CoV-2 infection and 4 additional patients with positive test results were subsequently hospitalized. 2 (18%) patients required admission to the intensive care unit. After 30 days' follow-up, no patients had died or required mechanical ventilation. No hemodialysis staff required hospitalization. Universal droplet and contact precautions were implemented during the outbreak. Hemodialysis staff with SARS-CoV-2 infection were placed on home quarantine regardless of symptom status. Patients with SARS-CoV-2 infection, including asymptomatic individuals, were treated with droplet and contact precautions until confirmation of negative SARS-CoV-2 RT-PCR test results. Analysis of the outbreak identified 2 index cases with subsequent nosocomial transmission within the dialysis unit and in shared shuttle buses to the hemodialysis unit. LIMITATIONS: Single-center study. CONCLUSIONS: Universal SARS-CoV-2 testing and universal droplet and contact precautions in the setting of an outbreak appeared to be effective in preventing further transmission.

Clinical characteristics and outcome of hemodialysis patients with COVID-19: a large cohort study in a single Chinese center.

BACKGROUND: Novel coronavirus disease (COVID-19) is spreading rapidly, which poses great challenges to patients on maintenance hemodialysis. Here we report the clinical features of 66 hemodialysis patients with laboratory confirmed COVID-19 infection. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Retrospective, single-center case series of the 66 hemodialysis patients with confirmed COVID-19 from 1 January to 5 March 2020; the final date of follow-up was 25 March 2020. RESULTS: The clinical data were collected from 66 hemodialysis patients with confirmed COVID-19. The incidence of COVID-19 in our center was 11.0% (66/602), of which 18 patients died. According to different prognosis, hemodialysis patients with COVID-19 were divided into the survival and death group. A higher incidence of fever and dyspnea was found in the death group compared with the survival group. Meanwhile, patients in the death group were often accompanied by higher white blood cell count, prolonged PT time, increased D-dimer (p < .05). More patients in the death group showed hepatocytes and cardiomyocytes damage. Furthermore, logistic regression analysis suggested that fever, dyspnea, and elevated D-dimer were independent risk factors for death in hemodialysis patients with COVID-19 (OR, 1.077; 95% CI, 1.014 to 1.439; p = .044; OR, 1.146; 95% CI, 1.026 to 1.875; p = .034, OR, 4.974; 95% CI, 3.315 to 6.263; p = .007, respectively). CONCLUSIONS: The potential risk factors of fever, dyspnea, and elevated D-dimer could help clinicians to identify hemodialysis patients with poor prognosis at an early stage of COVID-19 infection.

Creating arteriovenous fistulas for children in Guatemala.

OBJECTIVE: The Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala. METHODS: Three surgical pediatric VA missions were conducted in Guatemala from 2015 to 2017. Each mission was led by two or three surgeons. All supplies and equipment (including ultrasound units) were taken as part of each mission. The BOL surgical VA mission teams work with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships and foster teaching interactions. We retrospectively reviewed the patient demographic data, procedures, and outcomes for these missions. RESULTS: AVFs were created in 54 new pediatric patients. Ages were 8 to 19 years (13.4 ± 2.8 years) and 29 patients (54%) were male. Patient weights were 28 to 50 kg (30.8 ± 8.3 kg) with body mass indexes of 12 to 25 kg/m2 (17.9 ± 2.9 kg/m2). Radiocephalic AVFs were created in 21 children (39%), proximal radial artery AVFs in 12 (22%). and brachial artery inflow AVFs in 5 (9%). Sixteen patients (30%) required transpositions and one a translocation; two of these were femoral procedures. Primary and cumulative patency rates were 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. The median follow-up was 17 months. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage during the study period. However, six patients underwent an AVF revision and salvage during subsequent missions or by one of the Guatemalan surgeons (R.S.). Four individuals underwent successful transplantation during the study period. There were no operative deaths or major complications. CONCLUSIONS: Pediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months.

Longitudinal patterns of health-related quality of life and dialysis modality: a national cohort study.

BACKGROUND: Health-related quality of life (HrQoL) varies among dialysis patients. However, little is known about the association of dialysis modality with HrQoL over time. We describe longitudinal patterns of HrQoL among chronic dialysis patients by treatment modality. METHODS: National retrospective cohort study of adult patients who initiated in-center dialysis or a home modality (peritoneal or home hemodialysis) between 1/2013 and 6/2015. Patients remained on the same modality for the first 120 days of the first two years. HrQoL was assessed by the Kidney Disease and Quality of Life-36 (KDQOL) survey in the first 120 days of the first two years after dialysis initiation. Home modality patients were matched to in-center patients in a 1:5 fashion. RESULTS: In-center (n=4234) and home modality (n=880) patients had similar demographic and clinical characteristics. In-center dialysis patients had lower mean KDQOL scores across several domains compared to home modality patients. For patients who remained on the same modality, there was no change in HrQoL. However, there were trends towards clinically meaningful changes in several aspects of HrQoL for patients who switched modalities. Specifically, physical functioning decreased for patients who switched from home to in-center dialysis (p< 0.05). CONCLUSIONS: Among a national cohort of chronic dialysis patients, there was a trend towards different patterns of HrQoL life that were only observed among patients who changed modality. Patients who switched from home to in-center modalities had significant lower physical functioning over time. Providers and patients should be mindful of HrQoL changes that may occur with dialysis modality change.

Improved long-term survival with home hemodialysis compared with institutional hemodialysis and peritoneal dialysis: a matched cohort study.

BACKGROUND: The survival rate for dialysis patients is poor. Previous studies have shown improved survival with home hemodialysis (HHD), but this could be due to patient selection, since HHD patients tend to be younger and healthier. The aim of the present study is to analyse the long-term effects of HHD on patient survival and on subsequent renal transplantation, compared with institutional hemodialysis (IHD) and peritoneal dialysis (PD), taking age and comorbidity into account. METHODS: Patients starting HHD as initial renal replacement therapy (RRT) were matched with patients on IHD or PD, according to gender, age, Charlson Comorbidity Index and start date of RRT, using the Swedish Renal Registry from 1991 to 2012. Survival analyses were performed as intention-to-treat (disregarding changes in RRT) and per-protocol (as on initial RRT). RESULTS: A total of 152 patients with HHD as initial RRT were matched with 608 IHD and 456 PD patients, respectively. Median survival was longer for HHD in intention-to-treat analyses: 18.5 years compared with 11.9 for IHD (p <  0.001) and 15.0 for PD (p = 0.002). The difference remained significant in per-protocol analyses omitting the contribution of subsequent transplantation. Patients on HHD were more likely to receive a renal transplant compared with IHD and PD, although treatment modality did not affect subsequent graft survival (p > 0.05). CONCLUSION: HHD as initial RRT showed improved long-term patient survival compared with IHD and PD. This survival advantage persisted after matching and adjusting for a higher transplantation rate. Dialysis modality had no impact on subsequent graft survival.

The expanding role of "Stand-Alone" hemodialysis units in chronic renal replacement therapy: A descriptive study from North Kerala.

Renal replacement therapy in India is predominantly a private health-care-driven initiative making it an expensive treatment option due to high out-of-pocket expenditures. Moreover, with the rapid increase in the number of chronic kidney disease patients requiring dialysis, hemodialysis units (HDUs) are getting saturated. Community "stand-alone" dialysis centers could be an important alternative to HDUs in meeting the growing demand in an affordable model. The aim of this study was to find hemodialysis (HD) delivery in "stand-alone" dialysis units (SAUs) with respect to expanding coverage, patient costs, and patient safety safeguards. The total number of HD sessions was collected at three points. The information regarding patient safety safeguards at SAUs and impact of SAUs on patient costs were collected by interviews and from hospital records. There was 11.5 times increase in HD sessions from 2008 to 2017, out of which 75.3% was provided at SAUs. Following objective clinical and safety measures, high-quality dialysis was delivered at SAUs and it significantly reduced the mean patient cost of treatment per session.

Kidney transplant referral practices in southeastern dialysis units.

BACKGROUND: The Southeastern Kidney Transplant Coalition was created in 2010 to improve kidney transplant (KTx) rates in Georgia, North Carolina, and South Carolina. To identify dialysis staff-reported barriers to transplant, the Coalition developed a survey of dialysis providers in the region. METHODS: All dialysis units in the ESRD Network (n = 586) were sent a survey to be completed by the professional responsible for helping patients get transplants. RESULTS: One staff member at almost all (n = 546) of the dialysis units in Network 6 completed the survey (93% response rate). Almost all respondents reported being very comfortable (51.47%) or comfortable (46.89%) discussing the KTx process with patients. Just over half (56%) of facilities reported discussing KTx as a treatment option with patients on an annual basis. Fewer than one quarter of respondents (19%) perceived that more than 50% of their patients were interested in kidney transplant, and most of the staff surveyed (68%) reported that <25% of their dialysis patients completed the evaluation process and been wait-listed for a kidney transplant. CONCLUSION: The survey results provide insight into KTx referral practices in southeastern dialysis units that may be contributing to low KTx rates in this region.

Dialysis modality, vascular access and mortality in end-stage kidney disease: A bi-national registry-based cohort study.

AIM: There remains debate on which dialysis modality offers better survival outcomes for patients. We compare the survival of patients undergoing home haemodialysis (HD) with a permanent vascular access, facility HD with a permanent vascular access, facility HD with a central venous catheter or peritoneal dialysis. METHODS: We considered adult patients from the Australia and New Zealand Dialysis and Transplant Registry who commenced dialysis between 1 October 2003 and 31 December 2011. Patients were followed until death, transplant, loss to follow-up or 31 December 2011. Marginal structural models for mortality were used to account for time-varying treatment, comorbidities and baseline covariates. Unmeasured differences between treatment groups may remain even after adjustment for measured differences, so the potential effects of unmeasured confounding were explicitly modelled. RESULTS: There were 20,191 patients who underwent ≥90 days of dialysis (median 2.25 years, interquartile range 1-3.75 years). There were significant differences in age, gender, comorbidities and other variables between treatment groups at baseline. Thirty per cent of patients had at least one treatment change. Relative to facility HD with permanent access, the risk of death for home HD patients with a permanent access was lower in the first year (at 9 months: hazard ratio 0.41, 95% CI 0.25-0.67, adjusted for all baseline covariates). Findings were robust to unmeasured confounding within plausible ranges. CONCLUSION: Relative to facility HD with permanent vascular access, home HD conferred better survival prospects, while peritoneal dialysis was associated with a higher risk and facility HD with a catheter the highest risk, especially within the first year of dialysis.

Work-Related Factors as Predictors of Burnout in Serbian Nurses Working in Hemodialysis.

Nurses who work in hemodialysis (HD) are considered highly susceptible to burnout due to their close relationship with incurable patients and handling sophisticated machinery. A total of 210 nurses from 12 state-owned HD centers in the Republic of Serbia anonymously completed a background information questionnaire providingfactual data on nurses' sociodemographic characteristics and working conditions using the Maslach Burnout Inventory--Health Services Survey. Almost half of the nurses (42.9%) were experiencing burnout High emotional exhaustion, high depersonalization, and low level of personal accomplishment were present in 40.9%, 8.6%, and 31.3% of nurses, respectively. The number of children, involuntary choice of current position, and unwillingness to choose the same type of job again were significant predictors of burnout. Our population of nurses working in HD was more affected by emotional exhaustion than their colleagues in other countries, but maintained high level of empathy and feeling ofpersonal accomplishment.

Quality of life and emotional distress between patients on peritoneal dialysis versus community-based hemodialysis.

PURPOSE: Patient-reported outcomes are important endpoints to evaluate new models of renal delivery. This is the first study to compare Quality of Life (QOL) and emotional adjustment outcomes between patients on community-based hemodialysis (HD) and those on peritoneal dialysis (PD). METHODS: Data were collected between 2009 and 2011 from a cross-sectional sample of 232 HD patients and 201 PD patients recruited through community dialysis centers and outpatient PD clinics in Singapore. Participants completed the Hospital Anxiety and Depression Scale, World Health Organization Quality of Life Brief and the Short form for the Kidney Disease Quality of Life. Measures of ESRD severity, comorbidity and biochemistry were also collected. RESULTS: Physical and emotional QOL impairments were noted for both dialysis groups. Case-mix-adjusted comparisons indicated higher symptoms of depression (p = 0.027), and poorer physical health yet higher satisfaction with care (p = 0.001) in PD relative to community-based HD. CONCLUSIONS: Peritoneal dialysis regimes offer flexibility and autonomy under the support of PD teams. Although outcomes for most QOL domains measured were equivalent, PD patients are more satisfied with care but are at risk for emotional distress and provide poor ratings of physical health. Further research is needed to explore the expansion of standards of care to address psychosocial needs in PD populations.

Facility size, race and ethnicity, and mortality for in-center hemodialysis.

The association between dialysis facility size and mortality for patients undergoing hemodialysis remains largely unclear, and whether the relationship differs by race and ethnicity or among high-risk subgroups is not known. Using data from the USRDS, we analyzed mortality rates in 385,074 incident patients ages ≥ 18 years who received in-center hemodialysis at 4633 dialysis facilities between 2003 and 2009. Facilities were categorized by the number of hemodialysis stations (1-5, 6-10, 11-15, 16-20, 21-25, 26-30, 31-35, 36-45, 46-60, and ≥ 61 stations). We found significantly higher mortality associated with facilities comprising ≤ 15 stations, and within this group, mortality increased as the number of stations decreased. The association with increased mortality was weaker for facilities with 16-30 stations, but >30 stations offered no additional survival benefit. The association between increased mortality and facilities with ≤ 15 stations was stronger for racial minorities and patients with diabetes or cardiovascular diseases. After adjustments, blacks had a 78% greater 1-year mortality risk in facilities with one to five stations, whereas whites had only a 26% greater risk. Notably, other patient-related events remained comparable across the categories assessed. In summary, these data suggest that hemodialysis care at small facilities associates with a significant increase in mortality that is only partially explained by measured patient case mix, other well defined facility characteristics, and geographic region. Future studies should investigate differences in processes of care and practices among hemodialysis facilities of different sizes.

Burnout levels of hemodialysis nurses.

BACKGROUND: Previous studies have found significant stressors experienced by nurses working in hemodialysis units. The purpose of this study was to determine the burnout levels of hemodialysis nurses working in hemodialysis units and their relation with some sociodemographic variables. METHODS: The study was conducted between July 2012 and Sept 2012 in hemodialysis units of four hospitals, including one university, one public and two private hospitals, in the province of Erzurum. The population of the study consisted of 32 nurses rendering service in hemodialysis units of the related hospitals. Information forms, which were prepared by researchers in accordance with the literature, and aimed at determining the personal characteristics of nurses and Maslach Burnout Inventory were used for the data collection. RESULTS: Examining mean scores obtained by nurses from the Maslach Burnout Inventory, it is observed that they scored 17.07 ± 8.29 from subscale of emotional exhaustion, 5.89 ± 4.13 from subscale of depersonalization and 20.64 ± 4.10 from subscale of personal accomplishment. CONCLUSION: The results of the study revealed that nurses working in hemodialysis units experience a medium-level burnout in terms of subscales of emotional exhaustion, depersonalization, and a high-level burnout in terms of the subscale of personal accomplishment.

[The role of kidney transplantation in reducing mortality in a chronic dialysis program]. / Trasplante renal y disminución de la mortalidad en los programas de diálisis crónica.

For patients with chronic renal failure (CRF), kidney transplant (KT) is a better alternative to dialysis in terms of survival, life quality and costs. We studied the general characteristics, causes and survival rate of the dialysis population in 2010. We evaluated broader criteria for acceptance of transplants has affected the results of the procedure in that period. A total of 118 dialysis patients were included; mean age 56.9 ± 18.4 years, dialysis duration 45.5 ± 59.6 months, main cause of CRF was diabetes in 35 (30%), and 58 (49%) were included in waiting list for KT. Of the 34 patients who finished dialysis in 2010, 18 (53%) were KT, while 12 (35%) died (cardiovascular 50%, infectious 17%). Survival at 12 months was 85% for the total group, 98% on waiting list and 72% those who were not enrolled. During 2010 there were 88 KT, 62 with cadaveric donors (CD), 18 with living donors and 8 with double pancreas-kidney transplants. Recipients of CD were 50.7 years old, with 67 months on dialysis, 8 (13%) diabetics, and 12 (20%) with previous KT. Donors had a mean age of 45 years, 28 (45%) expanded criteria, and 27.7 hours of cold ischemia time. During an approximate follow-up of 11.4 months, 13 (21%) suffered acute graft rejection, survival was 88% for graft and 93% for patients. We emphasize KT as the main cause of success as regards dialysis. No differences in risk factors were found to significantly affect graft or patient survival.

Inequalities in transplant waiting list activation across Italian dialysis centers.

BACKGROUND: The demand for kidney transplant exceeds organ supply; therefore, understanding patient-related and contextual factors associated with waiting list activation is key in ensuring that organ allocation is efficient and equitable. We sought to assess whether inequalities in wait-listing probability exist across centers and evaluate correlates of wait-listing in Italy. METHODS: We linked the MigliorDialisi dataset (1,238 patients enrolled in 54 Italian hemodialysis centers) to administrative data concerning the activity of each participating center and contextual information abstracted from the Italian Institute of Statistics. We modeled the odds of waiting list activation for patients on dialysis by the subjects' sociodemographic, biomedical and psychosocial factors along with center-related and contextual factors. RESULTS: The crude enlistment rate was 26% (95% CI 9-54) distributed as follows: 21, 34 and 33% in northern, central, and southern Italy, respectively (p < 0.01). Older patients with poorer health conditions and lower expectations toward transplantation outcomes were less likely to be wait-listed in multilevel multivariable logistic regression. In the fully adjusted model there was not a statistically significant variation in wait-listing across northern, central, and southern regions. However, the variance explained by center-related factors accounted for 12% (p < 0.01) of total variability in enlistment likelihood (20% in patients >65 years, p < 0.01). CONCLUSIONS: Our results showed that inter-center variation exists after adjusting for case mix. Additionally, we identified individual modifiable factors associated with wait-listing inequalities.

UK Renal Registry 16th annual report: chapter 1 UK renal replacement therapy incidence in 2012: national and centre-specific analyses.

INTRODUCTION: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT: kidney dialysis or a kidney transplant) in the UK in 2012 and the incidence rates for RRT in Primary Care Trusts and Health Boards (PCT/HBs) in the UK. METHODS: Basic demographic and clinical characteristics are reported on patients starting RRT at all UK renal centres. Presentation time, defined as time between first being seen by a nephrologist and start of RRT, was also studied. Age and gender standardised ratios for incidence rates in PCT/HBs were also calculated. RESULTS: In 2012, RRT was initiated in 6,891 patients across the UK, an incidence rate similar to 2011 at 108 per million population (pmp). There were wide variations between PCT/HBs in standardised incidence ratios. The median age for Whites was 66.1 and for non-Whites 57.8 years. Diabetic renal disease remained the single most common cause of renal failure (26%). By 90 days, 66.9% of patients were on haemodialysis (HD), 19.0% on peritoneal dialysis (PD), 8.3% had had a transplant and 5.9% had died or stopped treatment. There was variability between centres in the use of PD as an initial treatment (3-48%). The mean eGFR at the start of RRT was 8.5 ml/min/1.73 m(2) similar to previous years. Late presentation (<90 days) fell from 23.9% in 2006 to 19.3% in 2012. Fifty-three percent of patients who started on HD had died within five years of starting. This compared to 30% and 4% for those starting on PD or transplant respectively. CONCLUSIONS: The incidence of new patients starting renal replacement therapy in the UK has remained unchanged for almost 10 years in contrast to the rising prevalence. The year on year increase in pre-emptive transplantation is encouraging but the variability between centres in the percentages starting on PD should be explored further.

UK Renal Registry 16th annual report: chapter 2 UK RRT prevalence in 2012: national and centre-specific analyses.

INTRODUCTION: This chapter describes the characteristics of adult patients on renal replacement therapy (RRT) in the UK in 2012. METHODS: Data were electronically collected from all 71 renal centres within the UK. A series of crosssectional and longitudinal analyses were performed to describe the demographics of prevalent RRT patients in 2012 at centre and national level. RESULTS: There were 54,824 adult patients receiving RRT in the UK on 31st December 2012. The UK adult prevalence of RRT was 861 pmp. This represented an annual increase in absolute prevalent numbers of approximately 3.7%, although there was variation between centres and Primary Care and Health Board areas. The actual number of patients increased across all modalities: 2.3% haemodialysis (HD), 0.3% peritoneal dialysis (PD) and 5.6% for those with a functioning transplant. The number of patients receiving home HD has increased by 19.3% since 2011. Median RRT vintage for patients on HD was 3.4 years, PD 1.7 years and for those patients with a transplant, 10.2 years. The median age of prevalent patients was 58 years (HD 66 years, PD 63 years, transplant 52 years) compared to 55 years in 2005. For all ages the prevalence rate in men exceeded that in women. The most common recorded renal diagnosis was glomerulonephritis (biopsy proven/not biopsy proven) (18.8%). Transplantation was the most common treatment modality (50.4%) CONCLUSIONS: The HD and transplant population continued to expand; the decline in the size of the prevalent PD population has plateaued. There were national, regional and dialysis centre level variations in prevalence rates. Prevalent patients were on average three years older than the prevalent RRT cohort 7 years ago. This has continued implications for service planning and ensuring equity of care for RRT patients.

Evaluating hospital readmission rates in dialysis facilities; adjusting for hospital effects.

Motivated by the national evaluation of readmission rates among kidney dialysis facilities in the United States, we evaluate the impact of including discharging hospitals on the estimation of facility-level standardized readmission ratios (SRRs). The estimation of SRRs consists of two steps. First, we model the dependence of readmission events on facilities and patient-level characteristics, with or without an adjustment for discharging hospitals. Second, using results from the models, standardization is achieved by computing the ratio of the number of observed events to the number of expected events assuming a population norm and given the case-mix in that facility. A challenging aspect of our motivating example is that the number of parameters is very large and estimation of high-dimensional parameters is troublesome. To solve this problem, we propose a structured Newton-Raphson algorithm for a logistic fixed effects model and an approximate EM algorithm for the logistic mixed effects model. We consider a re-sampling and simulation technique to obtain p-values for the proposed measures. Finally, our method of identifying outlier facilities involves converting the observed p-values to Z-statistics and using the empirical null distribution, which accounts for overdispersion in the data. The finite-sample properties of proposed measures are examined through simulation studies. The methods developed are applied to national dialysis data. It is our great pleasure to present this paper in honor of Ross Prentice, who has been instrumental in the development of modern methods of modeling and analyzing life history and failure time data, and in the inventive applications of these methods to important national data problem.