Direct Transition from Hospital to Home Dialysis: Revolutionizing Home Dialysis Training.

A large portion of new patients with end stage kidney disease initiates dialysis in the acute setting and continue with outpatient dialysis at in-center facilities. To increase home dialysis adoption, programs have successfully operationalized Urgent Start peritoneal dialysis to have patients avoid in-center dialysis and move straight to home. However, Urgent Start home hemodialysis (HHD) has not been a realistic option for providers or patients due to complex machines and long training times (greater than four weeks). The landscape of dialysis treatment is evolving, and innovative approaches are being explored to improve patient outcomes and optimize health care resources. This article delves into the concept of directly transitioning incident patients from hospital admission to HHD, bypassing traditional in-center dialysis training. This forward-thinking approach aims to empower patients, enhance their treatment experience, maximize efficiency, and streamline health care operations. A large hospital organization in the Northeast was able to successfully transition three patients from hospital "crash" starts on hemodialysis directly to HHD.

Impact of COVID-19 on Disease Self-management Among Patients With Advanced CKD: A Qualitative Study.

Rationale & Objective: Patients with advanced chronic kidney disease (CKD) and their care partners experienced decreased access to care, and worse physical and emotional health during the Coronavirus Disease-19 (COVID-19) pandemic. Few studies have explored how COVID-19-related challenges affected disease self-management among those with advanced chronic kidney disease (CKD) and their care partners. Leventhal's self-regulation model offers a comprehensive framework for understanding disease self-management through the interplay of cognitive beliefs, emotional reactions and social influences. The study aims to examine the impact of COVID-19 on self-management activities among patients with CKD and care partners. Study Design: Qualitative study. Setting & Participants: Adults with advanced CKD, including dialysis and transplant recipients, and their carepartners. Analytical Approach: Thematic Analysis. Results: Among 42 participants, 12 had stage 4 CKD, 5 had stage 5 CKD, 6 were receiving in-center hemodialysis, 5 had a kidney transplant, and 14 were care partners. We identified 4 patient-related themes with corresponding subthemes related to the impact of COVID-19 on self-management: 1) cognitive understanding that COVID-19 is an additional health threat to existing kidney disease, 2) heightened anxiety and vulnerability driven by perceived risk, 3) coping with isolation through virtual interactions with healthcare services and social circles, 4) increased protective behaviors to maximize survival. Three care partner-related themes emerged: 1) hypervigilance in family care and protection, 2) interaction with health system and adaptations to self-management, and 3) increased intensity in caregiving role to facilitate patient self-management. Limitations: The qualitative study design limits the ability to generate generalizable data. Grouping patients with Stage 3 and 4 CKD, in-center hemodialysis, and kidney transplants together limited our ability to examine self-management challenges specific to each treatment requirement. Conclusions: When faced with the COVID-19 pandemic, patients with CKD and their care partners experienced heightened vulnerability and thus increased cautionary activities to maximize survival. Our study provides the groundwork for future interventions to help patients and care partners live with kidney disease during future crises.

The Conversation: A Vital Element of Nephrology Care for Older Americans Who Are Medically Complex.

The U.S. population is aging, supported in part by continued development of life-prolonging medical therapies and technologies. These innovations, including kidney replacement therapies, have been effective in providing additional options to patients facing serious illness, but they have also introduced a new level of complexity in the provider assessment of treatment for these patients. Health care providers are being tasked to decide if medical care is appropriate for an aging and medically complex population, a decision complicated by a variety of factors. Patient-focused conversations surrounding goals of care, prognosis, medical futility, and quality of life need to become part of the routine practice pattern for nephrology care in the United States.

Medication discrepancies in late-stage chronic kidney disease.

BACKGROUND: Late-stage chronic kidney disease (LS-CKD) can be defined by glomerular filtration rate (GFR) 0-30 mL/min. It is a period of risk for medication discrepancies because of frequent hospitalizations, fragmented medical care, inadequate communication and polypharmacy. In this study, we sought to characterize medication discrepancies in LS-CKD. METHODS: We analyzed all patients enrolled in Northwell Health's Healthy Transitions in LS-CKD program. All patients had estimated GFR 0-30 mL/min, not on dialysis. Medications were reviewed by a nurse at a home visit. Patients' medication usage and practice were compared with nephrologists' medication lists, and discrepancies were characterized. Patients were categorized as having either no discrepancies or one or more. Associations between patient characteristics and number of medication discrepancies were evaluated by chi-square or Fisher's exact test for categorical variables, and two-sample t-test or Wilcoxon text for continuous variables. RESULTS: Seven hundred and thirteen patients with a median age of 70 (interquartile range 58-79) years were studied. There were 392 patients (55.0% of the study population) with at least one medication discrepancy. The therapeutic classes of medications with most frequently occurring medication discrepancies were cardiovascular, vitamins, bone and mineral disease agents, diuretics, analgesics and diabetes medications. In multivariable analysis, factors associated with higher risk of discrepancies were congestive heart failure [odds ratio (OR) 2.13; 95% confidence interval (CI) 1.44-3.16; P = 0.0002] and number of medications (OR 1.29; 95% CI 1.21-1.37; P < 0.0001). CONCLUSIONS: Medication discrepancies are common in LS-CKD, affect the majority of patients and include high-risk medication classes. Congestive heart failure and total number of medications are independently associated with greater risk for multiple drug discrepancies. The frequency of medication discrepancies indicates a need for great care in medication management of these patients.

Planning and evaluation for vascular access in the elderly.

Vascular access is of vital importance for patients requiring dialysis therapies. AV fistulas have been endorsed by many professional societies as the access of choice, however, subsequent creation does not go without consequences. As the population ages and patients become more medically complex, access failure has become a major cause of treatment complication. For the elderly, this is especially true and there are multiple decision points that require careful reflection before an AVF is placed. This article reviews access considerations for AVF placement in the elderly population and considers the possibility that the fistula first approach to vascular access should not be an absolute.

Augmented Nurse Care Management in CKD Stages 4 to 5: A Randomized Trial.

BACKGROUND: Outcomes for patients with late-stage chronic kidney disease (CKD) in the United States are suboptimal. There is poor education and preparation for end-stage kidney disease, as well as a high rate of hospitalization in this group of patients. STUDY DESIGN: A randomized, parallel-group, 2-arm, controlled trial. SETTING & PARTICIPANTS: The study was conducted at 3 sites: a clinic of an academic medical center, a public hospital academic clinic, and a community-based private practice. All participants had late-stage CKD (stages 4-5 CKD). Patients were excluded only if they had significant cognitive impairment. INTERVENTION: The care management intervention involved nurse care manager coordination aided by the use of a disease-based informatics system for monitoring patients' clinical status, enhancing CKD education, and facilitating preparation for end-stage kidney disease. The comparison control group received usual late-stage CKD care alone. OUTCOMES: The primary outcome was rate of hospitalization. MEASUREMENTS: Rates of preemptive transplantation, home dialysis, hemodialysis (HD) starts without a hospitalization, and HD therapy initiation rates with catheters or with functioning accesses. RESULTS: 130 patients were randomly assigned. The hospitalization rate was significantly lower in the intervention group versus controls: 0.61 versus 0.92 per year, respectively (incidence rate ratio, 0.66; 95% CI, 0.43-0.99; P=0.04). Peritoneal dialysis or preemptive transplantation was the initial end-stage kidney disease treatment in 11 of 30 (37%) participants receiving the intervention versus 3 of 29 (10%) receiving usual care. Among HD starts, treatment was initiated without hospitalization in 11 of 19 (58%) participants in the intervention group versus 6 of 26 (23%) in the control group. At the time of HD therapy initiation, a catheter was present in 7 of 19 (37%) participants in the intervention group versus 18 of 26 (69%) in the control group. A functioning arteriovenous access was in place in 10 of 19 (53%) participants in the intervention group and 7 of 26 (27%) in the control group LIMITATIONS: Moderate sample size, limited geographic scope. CONCLUSIONS: The augmented nurse care management intervention resulted in reduced hospitalizations in late-stage CKD and there were suggestions of improved end-stage kidney disease preparation. Given suboptimal outcomes in late-stage CKD, care management interventions could potentially improve patient outcomes.

Epidemiology and Challenges to the Management of Advanced CKD.

Advanced CKD is a period of CKD that differs greatly from earlier stages of CKD in terms of treatment goals. Treatment during this period presents particular challenges as further loss of kidney function heralds the need for renal replacement therapy. Successful management during this period increases the likelihood of improved transitions to ESRD. However, there are substantial barriers to optimal advanced CKD care. In this review, we will discuss advanced CKD definitions and epidemiology and outcomes.

Challenges and opportunities in late-stage chronic kidney disease.

There is increasing recognition that chronic diseases are a major challenge for health delivery systems and treasuries. These are highly prevalent and costly diseases and frequency is expected to increase greatly as the population of many countries ages. Chronic kidney disease (CKD) has not received the same attention as other chronic diseases such as congestive heart failure; yet, the prevalence and costs of CKD are substantial. Greater recognition and support for CKD may require that the disease no longer be viewed as one continuous disease state. Early CKD stages require less complex care and generate lower costs. In contrast, late-stage CKD is every bit as complex and costly as other major chronic diseases. Health authorities may not recognize and fund CKD care appropriately until late-stage CKD is defined clearly as separate and distinct from earlier stages of disease. In this review, we describe the burden of chronic diseases, consider the challenges and barriers and propose processes to improve late-stage CKD care. In particular, we recommend the need for improved continuity of care, enhanced use of information technology, multidisciplinary care, timely referral to nephrologists, protocol use and improved patient engagement.