Outcomes of Integrated Home Dialysis Care: Results From the Canadian Organ Replacement Register.

RATIONALE & OBJECTIVE: The integrated home dialysis model proposes the initiation of kidney replacement therapy (KRT) with peritoneal dialysis (PD) and a timely transition to home hemodialysis (HHD) after PD ends. We compared the outcomes of patients transitioning from PD to HHD with those initiating KRT with HHD. STUDY DESIGN: Observational analysis of the Canadian Organ Replacement Register (CORR). SETTINGS & PARTICIPANTS: All patients who initiated PD or HHD within the first 90 days of KRT between 2005 and 2018. EXPOSURE: Patients transitioning from PD to HHD (PD+HHD group) versus patients initiating KRT with HHD (HHD group). OUTCOME: (1) A composite of all-cause mortality and modality transfer (to in-center hemodialysis or PD for 90 days) and (2) all hospitalizations (considered as recurrent events). ANALYTICAL APPROACH: A propensity score analysis for which PD+HHD patients were matched 1:1 to (1) incident HHD patients ("incident-match" analysis) or (2) HHD patients with a KRT vintage at least equivalent to the vintage of PD+HHD patients at the transition time ("vintage-matched" analysis). Cause-specific hazards models (composite outcome) and shared frailty models (hospitalization) were used to compare groups. RESULTS: Among 63,327 individuals in the CORR, 163 PD+HHD patients (median of 1.9 years in PD) and 711 HHD patients were identified. In the incident-match analysis, compared to the HHD patients, the PD+HHD group had a similar risk of the composite outcome (HR, 0.88 [95% CI, 0.58-1.32]) and hospitalizations (HR, 1.04 [95% CI, 0.76-1.41]). In the vintage-match analysis, PD+HHD patients had a lower hazard for the composite outcome (HR, 0.61 [95% CI, 0.40-0.94]) but a similar hospitalization risk (HR, 0.85 [95% CI, 0.59-1.24]). LIMITATIONS: Risk of survivor bias in the PD+HHD cohort and residual confounding. CONCLUSIONS: Controlling for KRT vintage, the patients transitioning from PD to HHD had better clinical outcomes than the incident HHD patients. These data support the use of integrated home dialysis for patients initiating home-based KRT. PLAIN-LANGUAGE SUMMARY: The integrated home dialysis model proposes the initiation of dialysis with peritoneal dialysis (PD) and subsequent transition to home hemodialysis (HHD) once PD is no longer feasible. It allows patients to benefit from initial lifestyle advantages of PD and to continue home-based treatments after its termination. However, some patients may prefer to initiate dialysis with HHD from the outset. In this study, we compared the long-term clinical outcomes of both approaches using a large Canadian dialysis register. We found that both options led to a similar risk of hospitalization. In contrast, the PD-to-HHD model led to improved survival when controlling for the duration of kidney failure.

Combined Donor-Recipient Obesity and the Risk of Graft Loss After Kidney Transplantation.

Background: As the prevalence of obesity increases globally, appreciating the effect of donor and recipient (DR) obesity on graft outcomes is of increasing importance. Methods: In a cohort of adult, kidney transplant recipients (2000-2017) identified using the SRTR, we used Cox proportional hazards models to examine the association between DR obesity pairing (body mass index (BMI) >30 kg/m2), and death-censored graft loss (DCGL) or all-cause graft loss, and logistic regression to examine risk of delayed graft function (DGF) and ≤30 days graft loss. We also explored the association of DR weight mismatch (>30 kg, 10-30 kg (D>R; D

Predictors of Care Gaps in Home Dialysis: The Home Dialysis Virtual Ward Study.

BACKGROUND: Home dialysis patients may be at an increased risk of adverse events after transitional states. The home dialysis virtual ward (HDVW) trial was conducted in Canadian dialysis centers and aimed to evaluate potential care gaps and patient satisfaction during the HDVW. METHODS: The HDVW was a multicenter single-arm trial including peritoneal dialysis and home hemodialysis patients after 4 different events (hospital discharge, medical procedure, antibiotics, completion of training). Telephone-led interviews using a standardized assessment tool were performed over a 2-week period to assess a patient's care and adjust treatment as required. Upon completion, patients were surveyed to evaluate their perceived impact on domains of care using a rating scale; 1 not satisfied to 10 completely satisfied. RESULTS: The HDVW trial included 193 patients with a median number of potential care gaps/interventions of 1 (0-2) per patient. Patients admitted to the HDVW after hospital discharge were at a higher risk of potential gaps in care (OR 2.16, 95% CI 1.29-3.62), while longer dialysis vintage was -associated with a lower number of gaps/interventions (OR 0.97 per year, 95% CI 0.95-0.98). A total of 105/193 (54%) patients completed satisfaction surveys. Patients were highly satisfied with the HDVW (median rating scale score 8, IQR 2) and felt it had a positive impact (rating scale score ≥7) on their overall health, understanding of treatment and access to a nephrologist. CONCLUSION: The HDVW was effective at identifying several potential care gaps, and patients were satisfied across several domains of care. This intervention may be valuable in supporting home dialysis patients during care transitions.

A contemporary description of patients' estimated blood losses from diagnostic phlebotomy in a census of hospital episodes from a Canadian tertiary care center.

BACKGROUND: Phlebotomy for diagnostic testing is among the commonest hospital procedures, but hospital-wide surveys of all inpatients characterizing blood draw volumes have not been published. The objectives were to characterize the daily blood volumes drawn for diagnostic testing from patients discharged from a Canadian tertiary care center, describe the daily distributions of phlebotomy volumes across service locations, and describe changes in hemoglobin (Hb) and transfusion across service locations. STUDY DESIGN AND METHODS: Data were obtained on all patients discharged between 2012 and 2014 using linked discharge abstract and laboratory data. Cumulative daily blood volume and draw frequency were reported by service and days since admission. Changes in Hb and red blood cell (RBC) transfusion rates were reported for nontransfused and transfused patients. RESULTS: Data were included on 59,715 subjects. Mean daily estimated blood loss varied from 8.5 ± 6.5 mL/day onward to 27.2 ± 20.0 mL/day in the intensive care unit (ICU; p < 0.001). Phlebotomy volumes were highest on the first day of admission and declined thereafter (p < 0.001). For nontransfused individuals in the first week of admission, Hb levels decreased by the highest percentage in the ICU. The rate of RBC unit transfusion was highest in the ICU (232.4 units/1000 patient-days; 95% confidence interval, 225.8-239.2; p < 0.0001 compared with all other locations). CONCLUSION: Considerable variation was observed in estimated blood loss due to diagnostic phlebotomy across different services within one teaching hospital. Thi information is foundational for planning interventions to minimize estimated blood loss from phlebotomy.

The successful implementation of an automated institution-wide assessment of hemoglobin and ABO typing to dynamically estimate red blood cell inventory requirements.

BACKGROUND: Blood bank inventories must balance adequate supply with minimal outdate rates. The day-to-day practice of ordering red blood cell (RBC) inventory usually involves manually comparing current inventory levels with predetermined thresholds calculated from historical usage and ordering the difference. To date, there have been no published methods for ordering RBC inventory based on laboratory characteristics of admitted patients. STUDY DESIGN AND METHODS: We designed and implemented a blood ordering algorithm to provide a more accurate measure of predicted RBC utilization in our institution. Cerner Command Language (Cerner Millennium) was used to extract and combine historical RBC unit usage, current inventory levels, and system-wide hematology values and blood groups. This report contains a suggested order based on current inventory, historical inventory data, ABO group, and the current "anemia index" for the institution. RESULTS: The mean daily total RBC inventory was significantly reduced after implementation (401.7 units vs. 309.0 units, p < 0.05). There was a significant reduction in monthly RBC outdates in this period (19.1 vs. 8.1, p < 0.05). The age of RBCs at time of transfusion was reduced as well. CONCLUSION: We developed a novel algorithm that automatically generates a suggested RBC inventory order using real-time hospital-wide survey of patient ABO typing, hematology values, and historical data. After implementation of the algorithm we demonstrated a significant reduction in daily inventory levels and RBC outdate rates.

Short daily-, nocturnal- and conventional-home hemodialysis have similar patient and treatment survival.

Home hemodialysis (HHD) has many benefits, but less is known about relative outcomes when comparing different home-based hemodialysis modalities. Here, we compare patient and treatment survival for patients receiving short daily HHD (2-3 hours/5 plus sessions per week), nocturnal HHD (6-8 hours/5 plus sessions per week) and conventional HHD (3-6 hours/2-4 sessions per week). A nationally representative cohort of Canadian HHD patients from 1996-2012 was studied. The primary outcome was death or treatment failure (defined as a permanent return to in-center hemodialysis or peritoneal dialysis) using an intention to treat analysis and death-censored treatment failure as a secondary outcome. The cohort consisted of 600, 508 and 202 patients receiving conventional, nocturnal, and short daily HHD, respectively. Conventional-HHD patients were more likely to use dialysis catheter access (43%) versus nocturnal or short daily HHD (32% and 31%, respectively). Although point estimates were in favor of both therapies, after multivariable adjustment for patient and center factors, there was no statistically significant reduction in the relative hazard for the death/treatment failure composite comparing nocturnal to conventional HHD (hazard ratio 0.83 [95% confidence interval 0.66-1.03]) or short daily to conventional HHD (0.84, 0.63-1.12). Among those with information on vascular access, patients receiving nocturnal HHD had a relative improvement in death-censored treatment survival (0.75, 0.57-0.98). Thus, in this national cohort of HHD patients, those receiving short daily and nocturnal HHD had similar patient/treatment survival compared with patients receiving conventional HHD.

Burden of Emergency Medical Services Usage by Dialysis Patients.

BACKGROUND: Patients receiving chronic dialysis often require emergent and inpatient care; however, only a minimal amount is known about their out-of-hospital/inter-hospital use of Emergency Medical Services (EMS). The purpose of this study was to describe the utilization of EMS in a cohort of dialysis patients. METHODS: We analyzed a cohort of adult (≥18 years) chronic dialysis patients within the Nova Scotia Health Authority Central Zone Renal Program who initiated chronic dialysis between January 1, 2009 and June 30, 2013 (last follow up July 1, 2015). Dialysis patient data was linked to regional EMS data. Requests for EMS, including encounter type, day of the week, and patient characteristics were described. RESULTS: The cohort consisted of 468 patients of whom 79% (N = 361) had an EMS encounter. There were a total of 8,774 EMS encounters for the entire cohort. Patients who had an EMS encounter tended to be older (64 ± 14 years), compared to those without an encounter (55 ± 16 years, P < 0.001) and also had a higher burden of comorbidity. Transfers (including those between facilities) accounted for 89% of all encounters (N = 7,826), followed by emergency department (ED) transports (N = 749, 9%). Overall, 79% of all non-transfers underwent transport to the ED. For patients receiving thrice weekly in-center hemodialysis, the highest EMS utilization for ED transport occurred on the first hemodialysis day after the long dialysis break (22%, P < 0.01). The lowest proportion of ED transports occurred on the day after hemodialysis day 3. CONCLUSION: Utilization of EMS services by dialysis patients is considerable, particularly for transfers. This highlights a potential area to be targeted for reducing resource utilization. Calls requiring transport to the ED occurred most often on Mondays and Tuesdays, the day after the long-dialysis break, and may represent a time of heightened risk for in-center hemodialysis patients.

Frailty in end-stage renal disease: comparing patient, caregiver, and clinician perspectives.

BACKGROUND: Frailty is associated with poor outcomes for patients on dialysis and is traditionally measured using tools that assess physical impairment. Alternate measurement tools highlight cognitive and functional domains, requiring clinician, patient, and/or caregiver input. In this study, we compared frailty measures for incident dialysis patients that incorporate patient, clinician, and caregiver perspectives with an aim to contrast the measured prevalence of frailty using tools derived from different conceptual frameworks. METHODS: A prospective cohort study of incident dialysis patients was conducted between February 2014 and June 2015. Frailty was assessed at dialysis onset using: 1) modified definition of Fried Phenotype (Dialysis Morbidity Mortality Study definition, DMMS); 2) Clinical Frailty Scale (CFS); 3) Frailty Assessment Care Planning Tool (provides CFS grading, FACT-CFS); and 4) Frailty Index (FI). Measures were compared via correlation and sensitivity/specificity analyses. RESULTS: A total of 98 patients participated (mean age of 61 ± 14 years). Participants were primarily Caucasian (91%), male (58%), and the majority started on hemodialysis (83%). The median score for both the CFS and FACT-CFS was 4 (interquartile range of 3-5). The mean FI score was 0.31 (standard deviation ± 0.16). The DMMS identified 78% of patients as frail. The FACT-CFS demonstrated highest correlation (r = 0.71) with the FI, while the DMMS was most sensitive (97%, 100%) and a CFS ≥ 5 most specific (100%, 77%) at corresponding FI cutoff values (>0.21, >0.45). CONCLUSIONS: Frailty assessments of incident dialysis patients that include clinician, caregiver and patient perspectives have moderate to strong correlation with the FI. At specified FI cutoff values, the FACT-CFS and DMMS are highly sensitive measures of frailty. The CFS and FACT-CFS may represent viable alternative screening tools in dialysis patients.

Prolonged warm ischemia time is associated with graft failure and mortality after kidney transplantation.

Warm ischemia time is a potentially modifiable insult to transplanted kidneys, but little is known about its effect on long-term outcomes. Here we conducted a study of United States kidney transplant recipients (years 2000-2013) to determine the association between warm ischemia time (the time from organ removal from cold storage to reperfusion with warm blood) and death/graft failure. Times under 10 minutes were potentially attributed to coding error. Therefore, the 10-to-under-20-minute interval was chosen as the reference group. The primary outcome was mortality and graft failure (return to chronic dialysis or preemptive retransplantation) adjusted for recipient, donor, immunologic, and surgical factors. The study included 131,677 patients with 35,901 events. Relative to the reference patients, times of 10 to under 20, 20 to under 30, 30 to under 40, 40 to under 50, 50 to under 60, and 60 and more minutes were associated with hazard ratios of 1.07 (95% confidence interval, 0.99-1.15), 1.13 (1.06-1.22), 1.17 (1.09-1.26), 1.20 (1.12-1.30), and 1.23 (1.15-1.33) for the composite event, respectively. Association between prolonged warm ischemia time and death/graft failure persisted after stratification by donor type (living vs. deceased donor) and delayed graft function status. Thus, warm ischemia time is associated with adverse long-term patient and graft survival after kidney transplantation. Identifying strategies to reduce warm ischemia time is an important consideration for future study.

Vascular Access Type and Patient and Technique Survival in Home Hemodialysis Patients: The Canadian Organ Replacement Register.

BACKGROUND: While central venous catheter (CVC) use has expanded home hemodialysis (HHD) eligibility to many patients who may be unable to self-cannulate an arteriovenous (AV) access, the association between CVC use and mortality has not been directly examined among HHD patients. STUDY DESIGN: Registry-based retrospective observational cohort study. SETTING & PARTICIPANTS: Incident HHD patients in The Canadian Organ Replacement Register who had information for vascular access type (CVC vs AV access) within the first year of HHD therapy initiation. PREDICTOR: Use of a CVC versus an AV access (AV fistula or graft) within the first year of HHD therapy initiation. OUTCOME: The composite of all-cause mortality and technique failure (long-term transfer to an alternate dialysis modality). A Cox proportional hazards model was used to evaluate the adjusted composite outcome and each outcome separately. RESULTS: 1,869 patients initiated HHD therapy in Canada in 1996 to 2012, of whom 1,217 had an access type recorded within the first year of HHD therapy initiation. Compared to CVC use (n=523) and during a median follow-up of 513 and 427 days for AV access and CVC patients, respectively, AV access use (n=694) was associated with lower risk for the composite event of death and technique failure (490 events; adjusted HR, 0.78; 95% CI, 0.64-0.94) and lower adjusted all-cause mortality (129 deaths; adjusted HR, 0.63; 95% CI, 0.43-0.91); the risk for technique failure was nominally lower, but this result was not statistically significant (361 events; adjusted HR, 0.84; 95% CI, 0.67-1.05). Results were robust to sensitivity analyses and after missing data imputation. LIMITATIONS: Missing information for vascular access type (n=659[35% of patients]) and lack of information for longitudinal changes in vascular access type. CONCLUSIONS: Compared to CVC use, AV access use was associated with superior survival. Minimizing CVC use and maximizing AV access use while addressing barriers to their placement and self-cannulation may improve HHD outcomes.

Incidence, etiology, and significance of acute kidney injury in the early post-kidney transplant period.

Little is known about the incidence, causes, and significance of acute kidney injury (AKI) in the early transplant period. This study used a definition as >26 µmol/L increase in creatinine within 48 h or >50% increase over a period >48 h. In 326 adult consecutive recipients of a solitary kidney transplant from 2006 to 2014 followed at this center, 21% developed AKI within the first six months. Most etiologies were CNI toxicity (33%) or unknown (26%), whereas acute rejection accounted for 17% and urinary tract obstruction for 10%. Those with AKI had a significantly lower glomerular filtration rate (GFR) at one-yr post-transplant (adjusted beta coefficient -5.5 mL/min/1.73 m(2) , 95% CI: -10.4, -0.7, p = 0.025) in a multivariable linear regression model. However, the AKI definition missed 6 of 19 episodes of acute rejection and 4 of 10 episodes of urinary tract obstruction. When acute rejection (including those that did not satisfy AKI criteria) was included in the model, other causes of AKI were not significantly associated with GFR at year 1. Although AKI, using current criteria, is likely to be a significant predictor of later outcomes, important causes are missed and the criteria are not sensitive for clinical decision-making.

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.

Survival and hospitalization for intensive home hemodialysis compared with kidney transplantation.

Canadian patients receiving intensive home hemodialysis (IHHD; ≥16 hours per week) have survival comparable to that of deceased donor kidney transplant recipients in the United States, but a comparison with Canadian kidney transplant recipients has not been conducted. We conducted a retrospective cohort study of consecutive, adult IHHD patients and kidney transplant recipients between 2000 and 2011 at a large Canadian tertiary care center. The primary outcome was time-to-treatment failure or death for IHHD patients compared with expanded criteria, standard criteria, and living donor recipients, and secondary outcomes included hospitalization rate. Treatment failure was defined as a permanent switch to an alternative dialysis modality for IHHD patients, and graft failure for transplant recipients. The cohort comprised 173 IHHD patients and 202 expanded criteria, 642 standard criteria, and 673 living donor recipients. There were 285 events in the primary analysis. Transplant recipients had a reduced risk of treatment failure/death compared with IHHD patients, with relative hazards of 0.45 (95% confidence interval [95% CI], 0.31 to 0.67) for living donor recipients, 0.39 (95% CI, 0.26 to 0.59) for standard criteria donor recipients, and 0.42 (95% CI, 0.26 to 0.67) for expanded criteria donor recipients. IHHD patients had a lower hospitalization rate in the first year of treatment compared with standard criteria donor recipients and in the first 3 months of treatment compared with living donor and expanded criteria donor recipients. In this cohort, kidney transplantation was associated with superior treatment and patient survival, but higher early rates of hospitalization, compared with IHHD.

An international feasibility study of home haemodialysis in older patients.

BACKGROUND: Home haemodialysis (HHD) is undergoing a significant revival. There is a global demographic shift with a rising mean age of dialysis patients. We postulated that intensive HHD may also benefit the older dialysis population. However, there is a lack of literature on the feasibility of HHD in older patients with end-stage renal disease (ESRD). The purpose of this study was to ascertain the feasibility of delivering HHD to older patients. METHODS: We conducted a multi-centre multinational retrospective cohort study of HHD patients ≥65 years of age at the time of HHD initiation; 79 patients were included. Baseline demographic data included age at start of dialysis, race and sex. Dialysis characteristics including total weekly treatment hours, need for assistance, training time, dialysis access, modality and dialysis vintage were captured, as well as cause of ESRD and medical co-morbidities. The primary outcome was time to technique failure or death. Rates of hospitalization, cardiovascular events, non-infectious vascular access events and infections were collected. RESULTS: Median age at start was 68 (interquartile range 66-71) years. An arteriovenous fistula was the predominant access, and most patients were receiving <16 h of total weekly dialysis treatment. Family or nurse assistance for dialysis was required in 54% of patients. There were 17 (22%) deaths and 20 (26%) technique failures. The cumulative time at risk was 188 years. Event-free survival at 1, 2 and 5 years was 85, 77 and 24%, respectively, and technique survival was 92, 83 and 56%, respectively. Advancing age (categorized into quartiles) was an unadjusted risk factor for death and technique failure. CONCLUSIONS: This analysis confirms feasibility of HHD in patients 65 years or older at the start of this modality and should foster further research on the potential benefits of (intensive) HHD in older ESRD patients.

Rationale for a home dialysis virtual ward: design and implementation.

BACKGROUND: Home-based renal replacement therapy (RRT) [peritoneal dialysis (PD) and home hemodialysis (HHD)] offers independent quality of life and clinical advantages compared to conventional in-center hemodialysis. However, follow-up may be less complete for home dialysis patients following a change in care settings such as post hospitalization. We aim to implement a Home Dialysis Virtual Ward (HDVW) strategy, which is targeted to minimize gaps of care. METHODS/DESIGN: The HDVW Pilot Study will enroll consecutive PD and HHD patients who fulfilled any one of our inclusion criteria: 1. following discharge from hospital, 2. after interventional procedure(s), 3. prescription of anti-microbial agents, or 4. following completion of home dialysis training. Clinician-led telephone interviews are performed weekly for 2 weeks until VW discharge. Case-mix (modified Charlson Comorbidity Index), symptoms (the modified Edmonton Symptom Assessment Scale) and patient satisfaction are assessed serially. The number of VW interventions relating to eight pre-specified domains will be measured. Adverse events such as re-hospitalization and health-services utilization will be ascertained through telephone follow-up after discharge from the VW at 2, 4, 12 weeks. The VW re-hospitalization rate will be compared with a contemporary cohort (matched for age, gender, renal replacement therapy and co-morbidities). Our protocol has been approved by research ethics board (UHN: 12-5397-AE). Written informed consent for participation in the study will be obtained from participants. DISCUSSION: This report serves as a blueprint for the design and implementation of a novel health service delivery model for home dialysis patients. The major goal of the HDVW initiative is to provide appropriate and effective supports to medically complex patients in a targeted window of vulnerability. TRIAL REGISTRATION: (NCT01912001).

Suboptimal initiation of home hemodialysis: determinants and clinical outcomes.

BACKGROUND/AIMS: Suboptimal initiation of conventional hemodialysis is associated with poor clinical outcomes. In this study, we aimed to ascertain the determinants and adverse events associated with suboptimal starts in home hemodialysis (HHD). METHODS: We conducted a retrospective cohort study including consecutive incident HHD patients from January 1996 to December 2011. All patients had HHD as their first renal replacement therapy or returned to HHD after kidney transplantation. A suboptimal start was defined by dialysis initiation as an inpatient or with a central venous catheter. The primary outcome was time to first hospitalization, technique failure or death. Secondary outcomes included hospitalization rate, hospital days and determinants of suboptimal starts. Suboptimal starts were further categorized as unavoidable as adjudicated by two independent observers with prespecified criteria. RESULTS: Among 95 incident HHD patients, 44 (46%) and 51 (54%) had optimal and suboptimal starts, respectively. A suboptimal start was associated with a shorter time to the primary outcome (log-rank p < 0.001). In a multivariable Cox proportional hazards model, the hazard ratio for the composite outcome (comparing suboptimal to optimal starts) was 2.94 (95% confidence interval, CI, 1.49-5.78, p = 0.002). Transplantation clinic follow-up (OR 3.18, 95% CI 1.15-8.79) and the Charlson comorbidity index (OR 1.47, 95% CI 1.09-1.97) were associated with higher odds of suboptimal start. CONCLUSION: Suboptimal initiation of HHD is associated with adverse clinical events including early hospitalization. Given the high proportion of suboptimal starts in patients returning from transplantation, better incorporation of dialysis planning and renal replacement therapy education is warranted.

Attitudes and perceptions of nephrology nurses towards dialysis modality selection: a survey study.

BACKGROUND: There is a paucity of information about the views of dialysis nurses towards dialysis modality selection, yet nurses often have the most direct contact time with patients. We conducted a survey to better understand nurses' attitudes and perceptions, and hypothesized that nurses with different areas of expertise would have differences in opinions. METHODS: We administered an electronic survey to all dialysis/predialysis nurses (n = 129) at a large, tertiary care center. The survey included questions about preferred therapy - in-center hemodialysis (CHD), versus home dialysis (home hemodialysis and peritoneal dialysis) and ideal modality mix. Responses were compared between nurses with home dialysis and CHD experience. RESULTS: The survey response rate was 69%. Both nursing groups ranked patient caregivers and dialysis nurses as having the least impact on patient modality selection. For most patient characteristics (including age > 70 years and presence of multiple chronic illnesses), CHD nurses felt that CHD was somewhat or strongly preferred, while home dialysis nurses preferred a home modality (p < 0.001 for all characteristics studied). Similar differences in responses were noted for patient/system factors such as patient survival, cost to patients and nursing job security. Compared to CHD nurses, a higher proportion of home dialysis nurses felt that CHD was over-utilized (85% versus 58%, p = 0.024). CONCLUSION: Dialysis nurses have prevailing views about modality selection that are strongly determined by their area of experience and expertise.

Home dialysis in older adults: challenges and solutions.

There is a rising demand for dialysis in the older population given the increased numbers of older adults living with chronic kidney disease (CKD) progressing to kidney failure. Home dialysis, i.e. peritoneal dialysis (PD) and home hemodialysis (HHD), has been available for decades, but more recently there has been a rapid increase in home dialysis utilization as patients and clinicians consider its practical and clinical advantages. For older adults, incident home dialysis utilization more than doubled and prevalent home dialysis growth nearly doubled over the past decade. Whilst its advantages and recent rise in popularity are evident, there are numerous barriers and challenges that are important to consider prior to initiating older adults on home dialysis. Some nephrology healthcare professionals do not view home dialysis as an option for older adults. Successful delivery of home dialysis for older adults may be made even more difficult by physical or cognitive limitations, concerns around dialysis adequacy, and treatment-related complications, as well as challenges relating to caregiver burnout and patient frailty that are unique to home dialysis and older adults. Ultimately, it would be important for clinicians, patients and their caregivers to define what constitutes a 'successful therapy' to ensure treatment goals are aligned towards each individual's priorities of care, considering the complex challenges that surround an older adult receiving home dialysis. In this review, we evaluate some of the key challenges surrounding the delivery of home dialysis to older adults and propose potential solutions based on updated evidence to overcome these challenges.

Patient and Provider Gender and Kidney Transplant Referral in Canada: A Survey of Canadian Healthcare Providers.

BACKGROUND: Referral for kidney transplant (KT) is variable, with women often disadvantaged. This study aimed to better characterize Canadian transplant referral practices and identify potential differences by respondent and/or patient gender using surveys targeted at healthcare practitioners (HCPs) involved in KT. METHODS: Surveys consisting of 25 complex patient cases representing 7 themes were distributed to KT HCPs across Canada (March 3, 2022-April 27, 2022) using national nephrology/transplant society email registries. Respondents were asked whether they would refer the patient for transplant. Two identical surveys were created, differing only by gender/gender pronouns used in each case. Multivariable logistic regression was used to assess the association of respondent demographics and patient themes (including case gender) with the odds of transplant referral (overall and stratifying by respondent gender). RESULTS: Overall, the referral rate was 58.0% among 97 survey respondents (46.4% male). Case themes associated with a lower likelihood of referral included adherence concerns (adjusted odds ratio [aOR] 0.65; 95% confidence interval [CI], 0.45-0.94), medical complexity (aOR 0.57; 95% CI, 0.38-0.85), and perceived frailty (aOR 0.63; 95% CI, 0.47-0.84). Respondent gender was not associated with differences in KT referral (aOR 0.91; 95% CI, 0.65-1.26 for male versus female respondents) but modified the association of frailty (less referral for male than female respondents, P = 0.005) and medical complexity (less referral for female than male respondents, P = 0.009) with referral. There were no differences in referral rate by case gender ( P = 0.82). CONCLUSIONS: KT referral practices vary among Canadian HCPs. In this study, there were no differences in likelihood of transplant referral by candidate gender.