Infection-Related Hospitalizations in Home Hemodialysis Patients.

INTRODUCTION AND AIMS: Infection is an important cause of hospitalization and death in patients receiving hemodialysis (HD). Few studies have examined infection-related hospitalizations in home HD (HHD) population. The purpose of this study was to examine the scope of infections and the effect of HHD modality (daily home HD (DHD) and conventional home HD (CHD)) on infection-related hospitalizations in HHD patients. METHODS: The study was performed in a large cohort of HHD patients. Infection-related hospitalizations during July 1, 2005, and August 30, 2010, were abstracted from the centralized computer system. Data on demographics, dialysis vintage and dialysis modality were analyzed. RESULTS: One hundred sixty-five patients were included. During a median follow-up of 5 years, infection-related hospitalizations were observed in approximately 35.8% of all hospitalizations, which was the first cause for hospitalization. Rates of non-access-related infections were observed to be higher than that of access-related infections (1.7:1). Rates (per 100 person-years) of soft-tissue infection, pneumonia and sepsis ranged from 0.85 to 1.82 in patients on HHD. Meanwhile, access-related infection was the main cause for access-related hospitalizations (34.8%). Cox regression analysis showed that the usage of different dialysis modalities was not associated with a high risk for infection-related hospitalizations in HHD patients. CONCLUSIONS: Infection-related hospitalization occurred frequently in HHD patients. A broad range of infections, many unrelated to dialysis access, resulted in hospitalization in this population. HHD modalities were not associated with infection-related hospitalizations in HHD patients.

Systems to cultivate suitable patients for home dialysis.

The key to developing, initiating, and maintaining a strong home dialysis program is a fundamental commitment by the entire team to identify and cultivate patients who are suitable candidates to perform home dialysis. This process must start as early as possible in the disease trajectory, and must include a passionate and daily focus by physicians, nurses, social workers, and other members of the multidisciplinary team. This effort must be constant and sustained over months, with active promotion of home dialysis for suitable patients at every opportunity. Cultivation of suitable patients must become a defining and overarching mission for the entire program. This article reviews some of the components involved in this worthwhile effort and provides practical tips and links to resources.

Evaluation of a new method for pulse push/pull hemodialysis: comparison with conventional hemodialysis.

The repetition of forward and backward filtration during hemodialysis (HD) increases convective mass transfer, and thus, the authors devised a method of achieving cyclic repletion of ultrafiltration and backfiltration. Hemodialytic efficiencies of the developed unit are described. The devised method, named pulse push/pull hemodialysis (PPPHD), is based on the utilization of dual pulsation in a dialysate stream. Clearances of solutes with different molecular weights were determined, and in vivo hemodialytic performance was investigated in a canine renal failure model. Urea and creatinine reduction and albumin (ALB) loss were monitored, and the results obtained were compared with those of a conventional high-flux hemodialysis (CHD). Dialysis sessions were repeated eight times for PPPHD and six times for CHD by alternating PPPHD and CHD sessions in a single animal, which remained stable throughout the experiments. Urea and creatinine reductions for the PPPHD unit were 49.2 ± 2% and 44.3 ± 3.3%, respectively, which were slightly higher than those obtained for the CHD. Total protein and ALB levels were preserved by both methods. However, in vitro results revealed that PPPHD achieved significantly greater inulin clearance than CHD. The developed PPPHD unit facilitates repetitive filtration and improves convective mass transfer during HD, without the need for external replacement infusion.

Dialysis composite rate bundling: potential effects on the utilization of home hemodialysis, daily and nocturnal hemodialysis, and peritoneal dialysis.

Home hemodialysis was introduced because it was less expensive than center dialysis, so allowing more patients to be treated with the limited funds available in the 1960s. The start of the Medicare ESRD Program in July 1973, with almost universal entitlement, removed the financial barriers, and had many other effects including reducing the use of home dialysis. Bundled payment for dialysis, including necessary dialysis supplies and laboratory tests, was introduced as the "composite" rate in 1983. Over the ensuing years, the costs of providing dialysis treatment increased, and expensive new drugs were introduced, particularly erythropoietin. As a result, the government introduced a more extensive bundle at the beginning of this year, aimed at better control of costs. This article considers the potential effect of this reimbursement change on home dialysis.

The 50th anniversary of long-term hemodialysis: University of Washington Hospital, March 9th, 1960.

The first 6 months of 1960 saw the development of the shunt that first made long-term hemodialysis possible for patients dying from chronic kidney failure. A brief account of hemodialysis for acute kidney failure prior to 1960 is followed by a description of the work of Belding Scribner, Wayne Quinton and David Dillard at the University of Washington in Seattle. Scribner had the idea of a shunt connecting indwelling arterial and venous cannulas in the forearm between dialyses, to maintain patency of the cannulas, Quinton used Teflon tubing to make the device, and Dillard was the surgeon who implanted the first shunt on March 9th, 1960. The patient, Clyde Shields, was a 39-year-old man dying from uremia secondary to chronic glomerulonephritis. The shunt worked, and Clyde lived a further 11 years on dialysis. Scribner took Quinton and Clyde to the American Society for Artificial Internal Organs (ASAIO) meeting in April and showed Clyde to physicians interested in dialysis, and Quinton demonstrated fabrication of the shunt. In June 1960, 2 landmark papers describing cannulation and the treatment were published in the Transactions of the ASAIO. Today there are some 2 million patients with end-stage renal disease living worldwide.

Early dialysis in Britain: Leeds and beyond.

In parallel with the experience in most countries, early clinical experiments with dialysis in Britain did not lead to general adoption of the treatment. After a decade, dialysis for acute kidney failure was re-established at Leeds General Infirmary under the direction of Dr Frank Parsons, who had been inspired by Dr John Merrill in Boston. The intervening period was not characterized by indifference to kidney failure, but was devoted to defining acute kidney failure and successfully applying "conservative" measures, such as dietary regimens based on the scientific understanding and teaching of the time. The circumstances influencing the start of dialysis therapy at Leeds in 1956 and subsequent events up to the early 1960s are discussed in relation to the national medical scene.

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.