Design of therapeutic education workshops for home haemodialysis in a patient-centered chronic kidney diseases research: a qualitative study.

RATIONALE & OBJECTIVE: A quarter of patients do not receive any information on the modalities of renal remplacement therapy (RRT) before its initiation. In our facility, we provide therapeutic education workshops for all RRT except for home hemodialysis (HHD). The objectives of this study were to identify and describe the needs of CKD patients and caregivers for RRT with HHD and design therapeutic education workshops. SETTING & PARTICIPANTS: Two sequential methods of qualitative data collection were conducted. Interviews with patients treated with HHD and doctors specialized in HHD were performed to define the interview guide followed by semi-structured interviews with the help of HHD patients from our center. ANALYTIC APPROACH: Thematic analysis was conducted and were rooted in the principles of qualitative analysis for social scientists. Data were analyzed by two investigators. Transcribed interviews were entered into RQDA 3.6.1 software for data organization and coding purposes (Version 3.6.1). RESULTS: In total, five interviews were performed. We identified six themes related to the barriers, facilitators, and potential solutions to home dialysis therapy: (1) HHD allows autonomy and freedom with constraints, (2) safety of the care environment, (3) the caregiver and family environment, (4) patient's experience and experiential knowledge, (5) self-care experience and impact on life, and (6) factors that impact the choice of treatment with HHD. We designed therapeutic education workshops in a group of patients and caregivers. CONCLUSIONS: Our study confirmed previous results obtained in literature on the major barriers, facilitators, and potential solutions to HHD including the impact of HHD on the caregiver, the experiences of patients already treated with HHD, and the role of nurses and nephrologists in informing and educating patients. A program to develop patient-to-patient peer mentorship allowing patients to discuss their dialysis experience may be relevant.

Dialysis dose and mortality in haemodialysis: is higher better?

BACKGROUND: The effect of dialysis dose on mortality remains unsettled. Current guidelines recommend targeting a single-pool Kt/V (spKt/V) at 1.20-1.40 per thrice-weekly dialysis session. However, the optimal dialysis dose remains mostly disputed. METHODS: In a nationwide registry of all incident patients receiving thrice-weekly haemodialysis, 32 283 patients had available data on dialysis dose, estimated by Kt/V and its variants epuration volume per session (Kt) and Kt indexed to body surface area (Kt/A). Survival was analysed with a multivariate Cox model and a concurrent risk model accounting for renal transplantation. A predictive model of Kt in the upper quartile was developed. RESULTS: Regardless of the indicator, a higher dose of dialysis was consistently associated with better survival. The survival differential of Kt was the most discriminating, but marginally, compared with the survival differential according to Kt/V and Kt/A. Patient survival was higher in the upper quartile of Kt (>69 L/session) then deteriorated as the Kt decreased, with a difference in survival between the upper and lower quartile of 23.6% at 5 years. Survival differences across Kt distribution were similar after accounting for kidney transplantation as a competing risk. Predictive factors for Kt in the upper quartile were arteriovenous fistula versus catheters and graft, haemodiafiltration versus haemodialysis, scheduled dialysis start versus emergency start, long weekly dialysis duration and spKt/V measurement versus double-pool equilibrated Kt/V. CONCLUSIONS: Our data confirm the existence of a relationship between dialysis dose and survival that persisted despite correcting for known confounders. A model for predicting a high dose of dialysis is proposed with practical relevance.

Low incidence of SARS-CoV-2, risk factors of mortality and the course of illness in the French national cohort of dialysis patients.

The aim of this study was to estimate the incidence of COVID-19 disease in the French national population of dialysis patients, their course of illness and to identify the risk factors associated with mortality. Our study included all patients on dialysis recorded in the French REIN Registry in April 2020. Clinical characteristics at last follow-up and the evolution of COVID-19 illness severity over time were recorded for diagnosed cases (either suspicious clinical symptoms, characteristic signs on the chest scan or a positive reverse transcription polymerase chain reaction) for SARS-CoV-2. A total of 1,621 infected patients were reported on the REIN registry from March 16th, 2020 to May 4th, 2020. Of these, 344 died. The prevalence of COVID-19 patients varied from less than 1% to 10% between regions. The probability of being a case was higher in males, patients with diabetes, those in need of assistance for transfer or treated at a self-care unit. Dialysis at home was associated with a lower probability of being infected as was being a smoker, a former smoker, having an active malignancy, or peripheral vascular disease. Mortality in diagnosed cases (21%) was associated with the same causes as in the general population. Higher age, hypoalbuminemia and the presence of an ischemic heart disease were statistically independently associated with a higher risk of death. Being treated at a selfcare unit was associated with a lower risk. Thus, our study showed a relatively low frequency of COVID-19 among dialysis patients contrary to what might have been assumed.

Practice patterns of dialysis access and outcomes in patients wait-listed early for kidney transplantation.

BACKGROUND: Early kidney transplantation (KT) is the best option for patients with end-stage kidney disease, but little is known about dialysis access strategy in this context. We studied practice patterns of dialysis access and how they relate with outcomes in adults wait-listed early for KT according to the intended donor source. METHODS: This study from the REIN registry (2002-2014) included 9331 incident dialysis patients (age 18-69) wait-listed for KT before or by 6 months after starting dialysis: 8342 candidates for deceased-donor KT and 989 for living-donor KT. Subdistribution hazard ratios (SHR) of KT and death associated with hemodialysis by catheter or peritoneal dialysis compared with arteriovenous (AV) access were estimated with Fine and Gray models. RESULTS: Living-donor candidates used pretransplant peritoneal dialysis at rates similar to deceased-donor KT candidates, but had significantly more frequent catheter than AV access for hemodialysis (adjusted OR 1.25; 95%CI 1.09-1.43). Over a median follow-up of 43 (IQR: 23-67) months, 6063 patients received transplants and 305 died before KT. Median duration of pretransplant dialysis was 15 (7-27) months for deceased-donor recipients and 9 (5-15) for living-donor recipients. Catheter use in deceased-donor candidates was associated with a lower SHR for KT (0.88, 95%CI 0.82-0.94) and a higher SHR for death (1.53, 95%CI 1.14-2.04). Only five deaths occurred in living-donor candidates, three of them with catheter use. CONCLUSIONS: Pretransplant dialysis duration may be quite long even when planned with a living donor. Advantages from protecting these patients from AV fistula creation must be carefully evaluated against catheter-related risks.

A multinational cohort study of in-center daily hemodialysis and patient survival.

Increasing hemodialysis frequency from three to six times per week improves left-ventricular mass and health-related quality of life; however, effects on survival remain uncertain. To study this, we identified 556 patients in the International Quotidian Dialysis Registry who received daily hemodialysis (more than five times per week) between 2001 and 2010. Using propensity score-based matching, we matched 318 of these patients to 575 contemporaneous patients receiving conventional (three times weekly) hemodialysis in the Dialysis Outcomes and Practice Patterns Study. All patients had session times of <5 h, and received dialysis in the clinic or hospital setting. Mortality rates between groups were compared using Cox proportional hazards regression. Mean dialysis frequency in the daily group was 5.8 sessions per week. Mean weekly treatment time was 15.7 h for daily and 11.9 h for conventional patients. During 1382 patient-years of follow-up, 170 patients died. Those receiving daily hemodialysis had a significantly higher mortality rate than those receiving conventional hemodialysis (15.6 and 10.9 deaths per 100 patient-years, respectively: hazard ratio 1.6). Similar results were found in prespecified subgroup and sensitivity analyses. Unlike previous studies, we found that in-center daily hemodialysis was not associated with any mortality benefit. Thus, decisions to undertake daily hemodialysis should be based on quality-of-life improvements, rather than on claims of improved survival.

Prevalence of End Stage Kidney Disease and distribution of treatment modalities / Prévalence de l'IRCT et part des différentes modalités de traitement

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of ESKD prevalence, the following key messages were retained. While chronic kidney disease affects all age groups, there always are more patients to treat in the older age groups, with a median age of 71.1 years (IIQ 60.3-80.0) under dialysis and 58.7 years (IIQ 47.4-68.3) under renal transplant. Despite an increase in transplant activity and improved survival of grafts, the gap between the number of dialysis patients and transplant patients at the end of each year is only moderately reduced. There has been a moderate decrease in the proportion of in-centre haemodialysis that is explained by a significant increase in medicalised dialysis units (out-centre haemodialysis) and a decrease in self-care haemodialysis. Finally, a stable home-based care has been observed despite the ministerial incentives and the recommendations of the French-speaking scientific society (SFNDT-white paper).

À l'occasion des 20 ans du REIN (Réseau Epidémiologie et Information en Néphrologie), un travail de synthèse sur les apports du registre a été mené. Sur la question de la prévalence de la maladie rénale stade 5, les messages clés suivants ont été retenus. Si la maladie rénale chronique touche toutes les tranches d'âge, il y a toujours plus de patients à prendre en charge dans les tranches d'âge les plus élevées, avec un âge médian de 71,1 ans (Intervalle Inter Quartile (IIQ) 60,3-80,0) en dialyse et 58,7 ans (IIQ 47,4-68,3) en transplantation rénale. Malgré une augmentation de l'activité de greffe et une meilleure survie des greffons, l'écart entre le nombre de patients dialysés et greffés à la fin de chaque année ne diminue que de façon modérée. On observe une baisse modérée de la part de l'hémodialyse en centre expliquée par une hausse importante des unités de dialyse médicalisée (UDM) et une baisse de l'autodialyse. Enfin, on note une prise en charge à domicile stable malgré les incitations ministérielles et les recommandations de la société savante (SFNDT-livre blanc).

Short daily haemodialysis: survival in 415 patients treated for 1006 patient-years.

BACKGROUND: Survival statistics for daily haemodialysis are lacking as most centres providing this have treated only a small number of patients for short observation times. We pooled our 23-year, 1006-patient-year, five-centre experience of 415 patients treated by short daily haemodialysis. METHODS: One hundred and fifty patients were treated in-centre, most because of medical complications and 265 by home or self-care haemodialysis. Patients were on daily haemodialysis for 29 +/- 31 (0-272) months. Forty-two percent had primary and 31% had secondary renal failure. Treatment time was 136 +/- 35 min, frequency 5.8 +/- 0.5 times/week and weekly stdKt/V 2.7 +/- 0.55. RESULTS: Eighty-five patients (20%) died; 5-year cumulative survival was 68 +/- 4.1% and 10-year survival was 42 +/- 9%. Age, secondary renal failure and in-centre dialysis were associated with mortality, while gender, frequency of dialysis (5, 6 or 7 per week), continent, country and blood access were not. Survival was compared with matched patients from the USRDS 2005 Data Report using the standardized mortality ratio and cumulative survival curves. Both comparisons showed that the survival of the daily haemodialysis patients was 2-3 times higher and the predicted 50% survival time 2.3-10.9 years longer than that of the matched US haemodialysis patients. Survival of patients dialyzing daily at home was similar to that of age-matched recipients of deceased donor renal transplants. CONCLUSIONS: Survival of patients on short daily haemodialysis was 2-3 times better than that of matched three times weekly haemodialysis patients reported by the USRDS.

[Access to kidney transplantation's waiting list: Setting up a clinical pathway]. / Accès à la liste d'attente de transplantation rénale : mise en place d'un chemin clinique.

Early information about the kidney transplant is recommended to begin quickly the process of registration on the kidney transplantation waiting list, even for the patients not dialyzed at stage V of the renal insufficiency. It is a strategic choice for the patient care. From the arrival of all the patients in our center of dialysis, a systematic evaluation of the access to the kidney transplant waiting list is organized thanks to a clinical pathway. The impact of this new organization was estimated at 18 months with regard to the information about the kidney transplant transmitted to the patient, of the time required for the assessment of pre-kidney transplant evaluation, and of putting in contraindication. On 78 incident patients, 64 received the information concerning the kidney transplant. After 18 months, 50 clinical pathways are finalized at the time of the analysis among which 25 with a period lower than 6 days and 25 with a median of 169 days. A significant difference of age exists between both groups. The main causes of definitive medical contraindications were estimated. Twenty-two percent of the clinical pathway finalized is awaiting lifting of temporary contraindication. The management of the patient is improved, due to motivation of all the medical teams and a considerable work of coordination between the secretarial department and the department of transplantation in teaching hospital.

Six years' experience with short daily hemodialysis: do the early improvements persist in the mid and long term?

Observational studies from several groups have shown consistent beneficial effects in patients treated with short daily hemodialysis (SDHD). The cardiovascular and nutritional changes appear during the first few months after the initiation of SDHD. An extensive review of 17 patients from a group of 36 ESRD patients treated for up to 6 years with SDHD was undertaken to compare the clinicobiologic results during the initial period of standard hemodialysis (3 x 4 hr/week) and the short daily hemodialysis period at 1 year (SDHD(1)) and subsequent years (SDHD(2)). The statistical analysis of the clinicobiologic data clearly shows that the initial favorable results obtained during the first year of SDHD do persist in the mid and long term, which shows the more physiologic nature of this dialytic approach. The amelioration of left ventricular hypertrophy is of particular interest, showing a regression of ventricular dilation during the first year followed by a reduction of interventricular septum and posterior wall thickness during the subsequent years.

[Interests of advanced systematic evaluation of dialysis session]. / Intérêt d'une évaluation multicritères systématique de la séance de dialyse.

In order to rationalize the cost of care for dialysis patients in Centre, regulatory authorities urge establishments to favor the orientation of the patients in Medical Dialysis Unit where the medical presence is not permanent. This involves clinical skills for nurses in the conduct of the dialysis session. Faced with this changing work patterns, we present two security tools of the dialysis session. The first is a "check-list", simple, quick and easy to use, it enables secure connection phase of the patient. It was quickly integrated practice of all professionals. The second tool developed is a combination of indicators "DEAUP" for Pain, Purification, Blood access, Ultrafiltration and other Problems for assessing the quality of the course of the dialysis session. The aim is to reduce the occurrence of adverse events, the DEAUP rating certain criteria depending on the occurrence of incidents, from 0 to 2, 2 corresponding to the appearance of an incident having required the call of the doctor and constitute a precious tool of evaluation of the session for all the professionals. All nurses have joined the practice of evaluation, 98% of the realized sessions are informed and quoted; 8.4% of sessions required call nephrologists before or at the connection. The evaluation at the end of dialysis session found 15% of the sessions listed 2. Calls have resulted in an adjustment to the prescription of the sessions.

Heparin-grafted dialysis membrane allows minimal systemic anticoagulation in regular hemodialysis patients: a prospective proof-of-concept study.

This prospective, multicenter, proof-of-concept study aimed to evaluate the possibility to reduce the ordinary heparin dose and the systemic anti-Xa activity during hemodialysis (HD) sessions using a new heparin-grafted HD membrane. In 45 stable HD patients, the use of a heparin-grafted membrane with the ordinary heparin dose was followed by a stepwise weekly reduction of dose. Reduction was stopped when early signs of clotting (venous pressure, quality of rinse-back) occurred during two out of three weekly HD sessions. Heparin dose was decreased for 67% of patients resulting in the lowering of these patients' anti-Xa activity by 50%. Dose reductions were achieved with both types of heparin (low-molecular-weight heparin: 64 ± 14 to 35 ± 12 IU/kg, P < 0.0001; unfractionated heparin: 82 ± 18 to 46 ± 13 IU/kg, P < 0.0001) resulting in a decrease of anti-Xa activity at dialysis session end (low-molecular-weight heparin: 0.51 ± 0.25 to 0.25 ± 0.11 IU/mL, P < 0.0001; unfractionated heparin: 0.28 ± 0.23 to 0.13 ± 0.07 IU/mL, P < 0.0001). Failure to further decrease heparin dose was related to signs of clotting in blood lines (57% of sessions), in dialyzer (9%), or both (34%). Significant reduction of heparin dose and anti-Xa activity at the end of HD sessions was possible in stable HD patients using heparin-grafted membrane. HD patients who require low anti-Xa activity at the end of HD sessions might benefit from a heparin-grafted membrane to reduce bleeding risk and other heparin adverse events.

Survival with short-daily hemodialysis: association of time, site, and dose of dialysis.

In thrice-weekly hemodialysis, survival correlates with the length of time (t) of each dialysis and the dose (Kt/V), and deaths occur most frequently on Mondays and Tuesdays. We studied the influence of t and Kt/V on survival in 262 patients on short-daily hemodialysis (SDHD) and also noted death rate by weekday. Contingency tables, Kaplan-Meier analysis, regression analysis, and stepwise Cox proportional hazard analysis were used to study the associations of clinical variables with survival. Patients had been on SDHD for a mean of 2.1 (range 0.1-11) years. Mean dialysis time was 12.9 ± 2.3 h/wk and mean weekly stdKt/V was 2.7 ± 0.5. Fifty-two of the patients died (20%) and 8-year survival was 54 ± 5%. In an analysis of 4 groups by weekly dialysis time, 5-year survival continuously increased from 45 ± 8% in those dialyzing <12 hours to 100% in those dialyzing >15 hours without any apparent threshold. There was no association between Kt/V and survival. In Cox proportional hazard analysis, 4 factors were independently associated with survival: age in years Hazard Ratio (HR)=1.05, weekly dialysis hours HR=0.84, home dialysis HR=0.50, and secondary renal disease HR=2.30. Unlike conventional HD, no pattern of excessive death occurred early in the week during SDHD. With SDHD, longer time and dialysis at home were independently associated with improved survival, while Kt/V was not. Homedialysis and dialysis 15+ h/wk appear to maximize survival in SDHD.

Short daily hemodialysis and nutritional status in patients with chronic renal failure.

Malnutrition is a frequent complication in hemodialysis patients and is associated with increased mortality and morbidity. Interventions such as oral or intravenous nutritional supplements have often failed to improve nutritional status. We report here the effect that daily dialysis, practiced in our center since 1997, has had on nutritional parameters. Seventeen patients treated with conventional hemodialysis (4-5 hours, three times per week, for 9.6 +/- 8.4 years) were converted to short daily hemodialysis (2-2.5 hours, six times per week, for a mean of 39.1 +/- 23.5 months). Dietary, anthropometric, and biochemical evaluations were performed during conventional hemodialysis, after 1 year on short daily hemodialysis (sDHD(year)), and at the end of follow-up (sDHD(end)). Daily protein intake increased from 1.21 +/- 0.27 g/kg/day with conventional hemodialysis to 1.51 +/- 0.47 g/kg/day at sDHD(year) and 1.51 +/- 0.37 g/kg/day at sDHD(end). Energy intake increased from 33.6 +/- 9.5 kcal/kg/day to 38.3 +/- 10.9 kcal/kg/day at sDHD(year) and 39.4 +/- 9.4 kcal/kg/day at sDHD(end). The normalized protein equivalent nitrogen appearance (nPNA) increased from 1.19 +/- 0.34 g/kg/day with conventional hemodialysis to 1.34 +/- 0.43 g/kg/day sDHD(year) and 1.37 +/- 0.37 g/kg/day sDHD(end). Biochemical indicators also increased: serum albumin increased from 40.2 +/- 3.3 g/L to 44.5 +/- 4.6 g/L and 45.1 +/- 4.1 g/L, and prealbumin increased from 0.32 +/- 0.06 g/L to 0.38 +/- 0.09 g/L and 0.36 +/- 0.09 g/L, respectively. These improvements were accompanied by an increase in body weight from 62.0 +/- 10.6 kg on conventional hemodialysis to 64.3 +/- 10.2 kg at sDHD(year) and 65.5 +/- 9.7 kg at sDHD(end). All the changes between conventional hemodialysis and short daily hemodialysis were statistically significant. Increased frequency is more important than increased dialysis dose. Short daily hemodialysis appears to be a suitable method to improve nutritional status in dialysis patients.

Time Needed to Improve Clinical Parameters By Daily Hemodialysis.

Daily hemodialysis therapy (DHD), 2 hours, 6 times per week, is able to cure complications that persist on standard hemodialysis (SHD), 4 hours, 3 times per week. Cardiovascular manifestations (high blood pressure, left ventricular hypertrophy), nutritional deficient states, and postdialysis asthenia are improved during the first month of DHD therapy and are usually cured at 3 months. Daily hemodialysis may be considered as a rescue therapy. The next step will be to select which patients can return to the classical SHD therapy without recurrence of their complications.

Daily Hemodialysis versus Standard Hemodialysis: TAC, TAD, Weekly eKt/V, std(Kt/V), and PCRn.

Seven patients, mean age 42.57 ± 15.69 years (range 21 - 67 years), on standard hemodialysis (SHD), 4 - 5 hours, three times per week for 11.0 ± 6.63 years (range 1 - 18 years), were switched to daily hemodialysis (DHD), 2 - 2.5 hours, six times per week. For each type of treatment similar parameters were applied, and the total weekly time was the same. Mean duration of DHD was 15.4 ± 4.98 months (range 7 - 20 months). We report here our results of quantification in each method, including time-averaged concentration (TAC), normalized protein catabolic rate (PCRn), equilibrated Kt/V (eKt/V), equivalent normalized continuous standard clearance [std(Kt/V)], equivalent renal urea clearance (eKRn), and time-averaged deviation (TAD). With DHD, urea TAC was reduced from 19.09 ± 3.47 to 15.16 ± 3.21 mmol/L (p = 0.026), urea TAD diminished from 4.76 ± 1.04 to 2.52 ± 0.57 mmol/L (p = 0.000 53), PCRn increased from 1.11 ± 0.23 to 1.42 ± 0.24 g/kg/day (p = 0.001), weekly eKt/V increased from 4.11 ± 0.31 to 4.74 ± 0.43 (p = 0.000 25), std(Kt/V) rose from 2.17 ± 0.06 to 4.02 ± 0.25 (p = 0.0001), and eKRn increased from 12.96 ± 0.60 to 21.7 ± 3.09 mL/min (p = 0.000 45). On DHD the most important quantitative variation is the decrease of urea TAD (closer to that of a healthy kidney), due to the increased frequency of dialysis; std(Kt/V) practically doubled and represents 30% of that of normal renal function. These changes are probably the main explanation for the clinical improvements, but it is difficult to dissociate the effects of increased dialysis dose from the effects of decreased TAD.