The need for outpatient back-up for home hemodialysis patients: Implications for resource utilization.

INTRODUCTION: The provision of sufficient support contributes to home hemodialysis (HHD) technique survival. The need for back-up treatment in incident and prevalent patients on HHD has not been well described previously, and is important from both technique survival and resource allocation. We aimed to quantify the amount of back-up treatment given to patients in our HHD unit, and hypothesized that the provision of back-up HD facilitated technique survival. METHODS: This was a retrospective, single-center cohort study quantifying the provision of back-up HD between January and December 2018. Electronic and paper medical records were accessed for data collection. FINDINGS: One hundred and nineteen patients dialyzed independently at home during the study period (96 patient years of HHD). Seventy-eight (66%) patients required a total of 292 back-up HD sessions in the HHD unit, representing an average of three back-up HD runs per patient year of HHD. Fifty-three percent of back-up HD runs were required for vascular access related issues. The most common clinical issue requiring assessment and back-up HD was extracellular fluid volume management. An equal proportion (95%) of those that utilized back-up HD and those that did not utilize back-up HD maintained a positive disposition (transplant or ongoing HHD) in relation to technique survival in the short term. CONCLUSIONS: From a resource viewpoint, this program of approximately 100 HHD patients required the availability of one to two staffed HD stations each weekday for back-up HD. The provision of back-up HD was not a harbinger of HHD discontinuation.

The use of nurse-administered vascular access audit in home hemodialysis patients: A quality initiative.

INTRODUCTION: Vascular access complications are associated with increased morbidity and mortality in home hemodialysis (HHD). Nurse-administered vascular access checklist is a feasible quality improvement strategy aimed to lower HHD access errors. METHODS: We conducted a prospective quality improvement initiative for consecutive HHD patients between April 2013 and December 2016 at the Toronto General Hospital. Vascular access audits were administered every 6 months during clinic visits and during retraining sessions after an infection. We aimed to (1) determine whether prospective serial administration of vascular audit will decrease in the number of errors performed by the patient and (2) to determine whether there is an association between the number of errors and vascular access related infection. FINDINGS: A total of 370 audits were performed on 122 patients with a mean HHD vintage of 6.7 (0.8-19.5) years. The mean number of errors per patient decreased from 1.24 ± 1.75 (baseline) to 0.33 ± 0.49 (last follow-up), P < 0.001. Among patients who had serial vascular access audits performed, there was a significant decrease in median number of errors (baseline median 1, [0-2] end of study median 0, [0-1] P = 0.01). Patients performing buttonhole cannulation made most proportion of errors as compared to CVC, 54% vs. 40% (P = 0.01) respectively; and as compared to rope ladder cannulation 54% vs. 37% (P = 0.008). We were unable to demonstrate an association between the change in patient reported errors and vascular access related infection. DISCUSSION: Vascular access audit is a feasible quality initiative, which leads to a decrease in the number of patient reported errors in vascular access. The longitudinal clinical sequelae of this strategy warrants further examination.

A prototype line clamp for venous access bleeding in hemodialysis: A prospective cohort study.

INTRODUCTION: Venous needle dislodgement (or venous port disconnection) during hemodialysis (HD) may lead to catastrophic blood loss, particularly during unsupervised home HD. A prototype venous line clamp was developed for use in conjunction with the Redsense blood loss sensor. We hypothesize that this prototype device will provide additional safety to dialysis without excessive burden. METHODS: This was a single-center, prospective cohort study. Participants kept a log of bleeding, troubleshooting and clamp deployment events, and completed questionnaires before device first use and after device final use. The primary outcome was appropriate device function, evaluated by review of bleeding and clamp deployment events. The secondary outcomes were patient/nursing staff expectations and experience of the device. FINDINGS: Fourteen patients used the device during a combined total of 214 HD treatments. Five participants (36%) had experienced a bleeding or disconnection event prior to study recruitment. All vascular access types were represented. The device was tested during incenter HD (n = 7 patients) and home HD (n = 7 patients). There were eight clamp deployment events, three of which were in the setting of minor bleeding at the venous access site. No other bleeding events were reported. The main troubleshooting issues were related to cumbersome device connections. Participants perceived additional safety with the device (median score 4.25 out of 5; range 1-5). However, the amount of additional work created was variable, and large in some cases (median score 2 out of 5; range 0-4.5). There was no association between HD vintage and device burden (P = 0.55). DISCUSSION: This "proof of concept" study confirmed that a clamp on the venous line, operating in conjunction with a venous access blood detector, is feasible regardless of HD location or vascular access type. The device improved patient safety perception during HD but was burdensome. Design modifications could improve future device iterations.

Case of Mycobacterium mucogenicum in a home hemodialysis patient.

We present a case of a patient on home hemodialysis who developed Mycobacterium mucogenicum bacteremia. While infections with this particular organism are rare, disseminated infections have been reported and have been associated with significant morbidity and mortality. Diagnosis required appropriate cultures, understanding of natural habitat of organism and complete environmental analysis including blood, dialysis sample port, reverse osmosis and incoming water supply cultures. The patient was treated successfully with systemic antibiotics, removal of central venous catheter, patient education and complete exchange of the hemodialysis circuit.

The use of vascular access audit and infections in home hemodialysis.

Vascular access-related infection is an important adverse event in home hemodialysis (HHD). We hypothesize that errors in self-cannulation or manipulation of dialysis vascular access are associated with increased incidence of access-related infection. We conducted a retrospective cohort study of all prevalent HHD patients at the University Health Network. All vascular access-related infections were recorded from 2006 to 2013. Errors in dialysis access were ascertained by nurse-administered vascular access checklist. Ninety-two patients had completed at least one vascular access audit. Median HHD vintage was 2.3 (0.9-5.0) years in patients with appropriate vascular access technique and 5.8 (1.5-9.4) years in patients with erroneous vascular access technique. The overall rate of infection between patients with and without appropriate vascular access technique was similar (0.27 and 0.28 infections per year, P = 0.166). Among patients who were identified with errors in dialysis access manipulation, patients with five or more errors were associated with higher rate of access-related infection (mean of 0.47 vs. 0.16 infection per patient-year, P < 0.001). The use of vascular access audit is a feasible strategy, which can identify errors in vascular access technique. Patients with a longer median HHD vintage are associated with higher risk of inappropriate vascular access technique. Patients with multiple errors in vascular access technique are associated with a higher risk of dialysis access-related infection. Prospective evaluation of the impact of vascular access audit on adverse vascular access events is warranted.

Utility of Baseline Home Visit Audit in Home Hemodialysis.

We conducted a retrospective cohort study in a university hospital-based home hemodialysis (HHD) program to evaluate the effectiveness of a home visit audit tool. We aimed to delineate safety risk in HHD patients and to ascertain whether this is associated with clinical outcomes. All incident HHD patients between July 18, 2008, and June 30, 2013 with follow-up until December 31, 2013, were included in the cohort. Primary outcome was the description of the presence of safety risk evaluated by the home visit audit at the start of HHD. Secondary outcomes were patient-reported adverse events and technique survival. In our cohort of 84 patients, a baseline home visit audit was surveyed in 56 (67%) patients. Overall, patients were 45.8 ± 14.1 years old, and 51.2% were men. Eighteen of the 35 potential safety risks were documented at least once in the cohort. Thrity-three of the 56 surveyed subjects presented more than one safety risk. The performance of an audit did not influence adverse events or technique survival. Process and methods of auditing a home visit should be reviewed to improve judicious resource use.

Adverse technical events in home hemodialysis.

BACKGROUND: There is a growing interest in home hemodialysis because of its clinical benefits. However, given that patients are responsible for performing a complex medical procedure at home, adverse-event reporting is important to ensure patient safety. The purpose of this study was to describe adverse technical events in a large cohort of home hemodialysis patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: All consecutive patients undergoing home hemodialysis at a large tertiary-care center from 1999 through 2011 (last follow-up, July 2012). OUTCOMES: Overall rate of adverse technical events and number/rate of severe adverse events (defined as those requiring intervention). RESULTS: The cohort consisted of 202 patients with total follow-up of 757 patient-years. The cohort underwent a median of 5 dialysis treatments per week and 8 hours per session. 22 first adverse events and 7 recurrent events were identified. Adverse event rates were 0.049 per arteriovenous fistula access-year, 0.015 per arteriovenous graft access-year, and 0.022 per dialysis catheter access-year. Event rates per 1,000 dialysis treatments were 0.208, 0.068, and 0.087 for arteriovenous fistula, arteriovenous graft, and dialysis catheter access, respectively. Most adverse events were related to needle dislodgement (n=18) or air embolism (n=6). 8 adverse events resulted in emergency department visits and 5 required hospital admission. The rate of severe adverse events was 0.009 per patient-year of home hemodialysis and 0.038 per 1,000 dialysis treatments. Interventions included 3 blood transfusions, 2 catheter changes, 1 use of intravenous fluids, and 1 need for urgent dialysis. Attempts were made to retrain or review the technique in all patients with a first adverse event. LIMITATIONS: Events that were not severe may have been under-reported by patients. CONCLUSIONS: Serious adverse technical events in home hemodialysis are relatively rare. Strategies to further prevent these events may include patient retraining and periodic vascular access technique audit.

The use of alternative anti-coagulation strategies for a nocturnal home hemodialysis patient with heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a potentially catastrophic hyercoagulable state. The prevalence of HIT in individuals doing nocturnal home hemodialysis (NHD) is unknown and the appropriate treatment protocol has yet to be determined. The objective is to describe the clinical course and treatment plan ofa patient who developed HIT while undergoing NHD. A 49-year-old man with a past history of end stage renal disease (ESRD) of unknown etiology was initiated on NHD in February 2005. His clinical and biochemical parameters improved after conversion to NHD. However, excessive bleeding at the vascular access sites complicated his treatments. Clinical investigations revealed development of HIT Alternative therapeutic strategies were attempted to enable our patient to continue NHD: unfractionated heparin, citrated regional anticoagulation, Danaparoid, and Argatroban. In conclusion, NHD patients with HIT pose a specific clinical challenge. We speculate that the augmented exposure of heparin coupled with a primed autoimmune response may be responsible for the development of HIT in our patient. Further research is required to elucidate the appropriate clinical monitoring and treatment strategy for this patient.