BMC Nephrology

IntroductionHome dialysis (HoD) remains underutilized, despite evidence showing it provides comparable mortality rates to in-center hemodialysis (ICHD) while offering advantages such as improved quality of life and lower overall costs. This scoping review comprehensively evaluates the impact of public health interventions on increasing the use of HoD, including both Peritoneal Dialysis (PD) and Home Hemodialysis (HHD). MethodsRelevant studies were searched in the Web of Science, Medline, Embase, Scopus, EBSCOhost, and EconLit databases from their inception through May 2024. Studies were eligible for review if they assessed the effectiveness of public health interventions in terms of utilization and retention rates for general HoD, PD, and HHD. ResultsForty-three studies were included, with interventions categorized into three main types: educational programs, service provision improvements, and modifications to payment structures. Our findings indicate that educational interventions--aimed at enhancing knowledge about dialysis options and promoting shared decision-making among patients, families, and healthcare providers--and service provision improvements, such as assisted PD and nephrologist-performed catheter insertions, could significantly increase the initiation, utilization, and retention rates of HoD. However, the impact of payment interventions on HoD outcomes differed across different contexts. ConclusionEducation and service provision enhancements may represent the most effective public health interventions for increasing initiation, utilization, and retention rates of HoD in dialysis requiring patients. However, these findings are predominantly based on evidence from observational studies; further experimental studies with rigorous methodology are warranted to validate the effectiveness of these interventions in promoting HoD utilization. PLAIN TEXT SUMMARYKidney dialysis is a life-sustaining therapy that can be offered both at home and in medical centres, however, home dialysis is underutilised globally. This scoping review gathers evidence from around the world to identify and assess the effectiveness of public health interventions to improve home dialysis utilization. The interventions we found were mainly related to improving patient knowledge, redesigning service provision, or adjusting payment/reimbursement conditions. Our results suggest that educating patients about their dialysis options to support shared decision-making before they require dialysis and offering assisted peritoneal dialysis at home can help increase the number of patients starting and staying on home dialysis. However, adjusting payment and reimbursement policies showed mixed results.

Rationale & ObjectivePerson-centered care (PCC), which incorporates patients preferences and values not only for medical care but also for their life, in decision making has been proposed for promoting advance care planning (ACP) among patients with kidney failure. However, how variations in PCC affect ACP participation remain unclear. Therefore, we examined variations in PCC across facilities and examined the association between PCC and ACP participation. Study DesignMulticenter cross-sectional study. Setting & ParticipantsJapanese adults receiving outpatient hemodialysis at six dialysis centers. ExposuresPCC was measured using the 13-item Japanese version of the Primary Care Assessment Tool-short form. OutcomeACP participation as defined by discussion with the attending physician or written documentation or notes regarding treatment preferences. Analytical ApproachA general linear model was used to examine the correlates of the quality of PCC. Modified Poisson regression models were used to examine the associations of ACP participation. ResultsA total of 453 individuals were analyzed; 26.3% participated in ACP. Compared to respondents with no usual source of care (USC), higher PCC was associated with greater ACP participation in a dose-response manner (vs. no USC, adjusted prevalence ratios for the first to fourth quartiles: 1.36, 2.31, 2.64, and 3.10, respectively). Among the PCC sub-domains, first contact, longitudinality, comprehensiveness (services provided), and community orientation were particularly associated with ACP participation. There was a maximum of 12.0 points of facility variation in the quality of PCC. LimitationsPossible reverse causation and unmeasured confounders. ConclusionsHigh PCC quality was associated with ACP participation. The substantial disparity in PCC between facilities provides an opportunity to revisit the quality improvement in PCC.

BackgroundThe healthcare-related burden associated with kidney replacement therapy (KRT) has not been characterised as comprehensively in peritoneal dialysis (PD) as in haemodialysis (HD) or kidney transplantation. This study aimed to capture the nature and extent of healthcare activity in the first year of PD therapy. MethodsRetrospective analysis was undertaken on consecutive incident adult patients on PD between 1st January 2015-31st December 2019 in the Glasgow Renal and Transplant Unit. Healthcare-related activity was captured up to the first 365 days post-commencement of PD. Data was collected on renal service contact and activity relating to dialysis access, radiological investigation, and relevant infection episodes. Carbon mapping of healthcare activity was estimated using postcode data and previously published carbon footprint estimations. ResultsPD was initiated in 122 patients over the study period. Sixty-three patients (52%) transitioned to another KRT within 365 days of commencing PD. Patients had a mean 36.4 days (SD 22.7) of face-to-face contact days with renal services. This included a mean of 1.5 (SD 1.6) hospital admissions, with a median 5 (IQR 10.8) in-patient days. The estimated carbon footprint was 581kg CO2e/patient over the incident year. This included a median 207kg CO2e/patient for inpatient days and 26kg CO2e/patient for treatment of infections. ConclusionsThere is a significant burden of kidney-associated healthcare on patients commencing their first year of PD despite it being a home-based therapy. Estimates of carbon footprint indicate hotspots include patient travel and hospital admissions, and episodes of peritonitis; a full life cycle analysis is merited. Key Learning PointsO_ST_ABSWhat was knownC_ST_ABSO_LIThe characterisation of healthcare-related activity to be expected with peritoneal dialysis therapy is not as comprehensive as that for haemodialysis and kidney transplantation. C_LIO_LIPatient-centred realistic medicine requires knowledge of the patient journey and the cumulative impact of healthcare activity interactions. C_LIO_LIHealthcare activity burden mapping is required to determine the necessary carbon emission reductions for reducing the contribution to climate change. C_LI This study addsO_LIAn illustration of the associated health-care activity burden on patients commencing peritoneal dialysis. C_LIO_LIAn indication of the carbon footprint associated with peritoneal dialysis health-care activity in the first year of therapy. C_LI Potential impactO_LIInformative for service providers of peritoneal dialysis in anticipating care requirements and planning carbon reduction strategies. C_LIO_LIData can help inform patient decision making when receiving education of kidney replacement therapies. C_LI

Rationale & ObjectiveBasic health literacy (HL) and trust in physicians can influence medication adherence (MA) in dialysis patients. However, how high-order HL is associated with MA, and how trust in physicians mediates this association remain unclear. We assessed the interrelationships between HL, trust in physicians, and MA, and investigated the mediating role of trust in physicians in the relationship between HL and MA. Study DesignMulticenter cross-sectional study. Setting & ParticipantsJapanese adults receiving outpatient hemodialysis at six dialysis centers. ExposuresMultidimensional HL was measured using the 14-item Functional, Communicative, and Critical Health Literacy Scale. Trust in physicians was measured using the five-item Wake Forest Physician Trust Scale. OutcomeMA was measured using the 12-item Adherence Starts Knowledge (ASK-12) scale. Analytical ApproachA series of general linear models was created to analyze the associations between HL and ASK-12 scores with and without trust in physicians. Mediation analysis was performed to determine whether trust in physicians mediated this association. ResultsIn total, 455 patients were analyzed. Higher functional and communicative HL were associated with lower barriers to MA (per 1-point increase: -1.90 (95% confidence interval (CI): -2.67, -1.13) and -2.11 (95% CI: -3.35, -0.87), respectively), whereas higher critical HL was associated with higher barriers (per 1-point increase: 1.67 (95% CI: 0.43, 2.90)). After controlling for trust in physicians, the magnitude of the association between HLs and MA decreased. Trust in physicians partially mediated the association between functional or communicative HL and MA (especially "beliefs") and completely mediated the association between critical HL and MA (especially "behaviors"). LimitationPossible reverse causation. ConclusionsIn addition to functional HL, communicative and critical HL were associated with MA, and their associations were mediated by trust in physicians. To effectively improve MA, individualized strategies for each HL and favorable physician-patient interactions are important.

IntroductionLifestyle interventions have been shown to produce favorable changes in some health outcomes in patients with chronic kidney disease (CKD). However, few such studies, employing "real world" methods have been completed in patients with CKD. ObjectiveThis study tested the effectiveness of a comprehensive, multicomponent, lifestyle intervention, delivered through individualized counseling on a variety of health outcomes in pre-dialysis CKD patients. MethodsEligible patients were assigned randomly to the intervention (TR) or usual care group (UC). A six-month home-based program involving personalized counseling to increase physical activity to recommended levels among stage G3a to G4 CKD patients while exchanging plant proteins for animal proteins was implemented. Physical function, cardiovascular function, dietary intake, medication use, and health-related quality of life (HRQOL) were assessed at baseline and after 1-month, 3-months (M3) and 6-months (M6). ResultsForty-two, patients (age 60.2 {+/-} 9.2, BMI 34.5 {+/-} 7.8) participated in this study (TR=27 UC=15). The intervention reduced (p<0.05) brachial (bSBP) and central systolic blood pressures (cSBP) at month 3 (M3) but both were attenuated at month 6 (M6). Scores on the effect of kidney disease subscale of the HRQOL measure improved in the intervention group at M3 and M6. There was no change in the other measures of HRQOL or in any physical function scores. ConclusionsThis personalized multi-component lifestyle intervention enabled CKD patients to self-report fewer concerns with how CKD affected their daily lives independent of changes in physical function.

ObjectiveThe objective of this scoping review is to describe how exercise has been prescribed for hemodialysis patients. IntroductionExercise interventions have received more attention from the nephrology community in the last few years. Despite some limitations in the findings, there is currently robust evidence suggesting that exercise is clinically important and provides benefits to hemodialysis patients. Even so, there is little evidence precisely detailing and describing how exercise can be prescribed and delivered for this population. Inclusion criteriaBased on the PCC framework, we will review and include evidence from hemodialysis patients (Participants); describing exercise interventions (Concept); in all settings and designs (Context). The evidence that included any other kidney replacement therapy other than hemodialysis will be excluded. MethodsThis review will follow the JBI methodology for scoping reviews and the PRISMA-ScR. We will perform a comprehensive literature search using MEDLINE, EMBASE, SPORTDiscuss, CINAHL, and LILACS databases without date or language restrictions from inception until December 2021. Websites, books, and guidelines from prominent societies and associations will also be searched. Experimental, quasi-experimental, observational, and protocol evidence from adults with chronic kidney disease ([&ge;]18 years) undergoing hemodialysis that prescribed exercise as an intervention will be considered. Two independent reviewers will screen title and abstract and perform the full-text review. Data extraction will be done by the main reviewer and checked by a second reviewer. Data characterizing the exercise interventions (e.g., type, setting, frequency, duration, intensity, volume, progression, periodization, professionals involved, etc.) will be extracted from selected evidence. The qualitative and quantitative results will be synthesized and presented in tables and figures along with a narrative summary.

BackgroundDry heat, immersive, and Hammam sauna baths have been shown to aid fluid removal in haemodialysis patients but require high ambient temperatures, large volumes of water and sufficient space, all of which limit their widespread use in India. We aimed to study the safety and efficacy of a commercially available, inexpensive, portable steam sauna bath for this purpose. MethodsIn this pilot phase II clinical trial, six adult prevalent haemodialysis patients each underwent 6 sauna sessions lasting 30-60 minutes, on all non-dialysis days, for 2 weeks. Weight, blood pressure, serum urea, creatinine, electrolytes, haematocrit, core body temperature, thermal comfort, and thirst visual analogue scale were measured before and after each session. Karnofsky performance status (KPS) and Dialysis Symptoms Index (DSI) were measured at the beginning and end of the intervention period. The primary end points were per session weight loss and interdialytic weight gain (IDWG). ResultsPatients experienced a median weight loss of 0.35 kg, median fall in systolic and diastolic BP of 10 mm Hg and 2 mm Hg respectively (p < 0.001 for all) without significant change in IDWG (p = 0.46). Mean thermal comfort was 5.41 {+/-} 0.56 out of 8, there was no significant increase in thirst (p = 0.06) and no significant change in KPS and DSI scores (p = 1.00 and 0.32 respectively). No adverse events were noted. ConclusionsThe portable steam sauna is safe, but modestly effective for fluid removal in haemodialysis patients, and may not influence IDWG. Details of each authors contributions O_TBL View this table: org.highwire.dtl.DTLVardef@1b1459org.highwire.dtl.DTLVardef@1d4e64borg.highwire.dtl.DTLVardef@5b5018org.highwire.dtl.DTLVardef@e79877org.highwire.dtl.DTLVardef@cabb74_HPS_FORMAT_FIGEXP M_TBL C_TBL

ImportanceFrailty is common among dialysis patients and significantly affects the quality of life for both patients and their caregivers. However, limited evidence exists on the long- term changes in physical function in this population. ObjectiveTo examine 8-year trajectories of physical function and assess associations with baseline dialysis duration and physical function status among Japanese dialysis patients. DesignNationwide, cohort study. SettingJapan; data obtained from a registry. Participants223,501 Japanese adults receiving hemodialysis enrolled in the 2010 Japanese Society for Dialysis Therapy Renal Data Registry. ExposuresBaseline dialysis duration (<5, 5-<10, 10-<20, 20-<30, [&ge;]30 years) and physical function were assessed using the Eastern Cooperative Oncology Group Performance Status, categorized as non-frail, frail, or bedridden. Main Outcomes and MeasuresPhysical function at 8 years was similarly classified as non- frail, frail, bedridden, or deceased. Multinomial logistic regression was used to estimate adjusted odds ratios, average marginal effects, and predicted probabilities based on baseline exposures. ResultsAmong patients with complete baseline and 8-year follow-up data, 59.9% died, 8.8% became frail, 2.4% were bedridden, and 28.9% remained non-frail. Longer dialysis duration and baseline frailty or bedridden status were associated with increased odds of subsequent frailty, bedridden status, and mortality. Compared with patients with <5 years of dialysis, those with [&ge;]30 years had a 1.6% (95% confidence interval, 0.6%-2.6%) higher probability of frailty and a 13.0% (95% confidence interval, 11.8%-14.3%) higher probability of death. Compared with non-frail status at baseline, frailty was associated with a 0.0% (95% confidence interval, -0.4% to 0.4%) change in frailty and a 15.8% (95% confidence interval, 14.5%-17.0%) increase in death; bedridden status was associated with a 1.7% (95% confidence interval, 1.1%-2.3%) increase in being bedridden and a 27.6% (95% confidence interval, 26.5%-28.8%) increase in death. Conclusions and RelevanceIn this nationwide 8-year study, majority of the hemodialysis patients experienced either death or functional decline. Longer dialysis duration and baseline frailty were associated with adverse outcomes, although absolute increases in frailty were modest. These findings highlight the need for early, values-based shared decision-making in the management of dialysis patients.

IntroductionSeveral comorbid conditions, have been identified as risk factors in patients with COVID-19. However, there is a dearth of data describing the impact of COVID-19 infection in patients with end-stage renal disease on hemodialysis (ESRD-HD). MethodsThis retrospective case series analyzed 362 adult patients consecutively hospitalized with confirmed COVID-19 illness between March 12, 2020 and May 13, 2020, at a teaching hospital in the New York City metropolitan area. Primary outcome was severe pneumonia as defined by the World Health Organization. Secondary outcomes were: 1) the Combined Outcome of Acute respiratory distress syndrome or in-hospital Death (COAD), and 2) the need for High-levels of Oxygen supplementation (HiO2). ResultsPatients with ESRD-HD had lower odds for poor outcomes including severe pneumonia [Odds Ratio (OR) 0.4, Confidence Interval (CI) (0.2-0.9) p=.04], HiO2 [OR 0.3, CI (0.1- 0.8) p=.02] and COAD [OR 0.4, CI (0.2-1.05) p=.06], when compared to patients without ESRD. In contrast, higher odds for severe pneumonia, COAD and HiO2 were seen with advancing age. African-Americans were over-represented in the hospitalized patient cohort, when compared to their representation in the community (35% vs 18%). Hispanics had higher odds for severe-illness and HiO2 when compared to Caucasians. ConclusionsPatients with ESRD-HD had a milder course of illness with a lower likelihood of severe pneumonia and a lesser need for aggressive oxygen supplementation when compared to patients not on chronic dialysis. This "protective effect" might have a pathophysiologic basis and needs to be further explored.

Arteriovenous (AV) access choice has sparked controversy with recent evidence suggesting overestimation of benefits associated with AV fistula versus graft in certain populations. We assessed outcomes associated with first-line AV access type in patients who started hemodialysis with a catheter in France, overall and by subgroups of age, sex, and comorbidities. In this retrospective cohort study, we included incident patients who initiated hemodialysis with a catheter from 2010 through 2018, followed by the French REIN Registry. Our main exposure was the first-line (first-created) AV graft versus fistula, ascertained through the linkage with the French national health-administrative database. Outcomes were all-cause and cause-specific hospitalization, and all-cause mortality. We used joint frailty models to deal with recurrent hospitalizations and informative censoring by death, Cox proportional hazard (PH) models, and inverse probability weighting. From the 18,625 patients included (mean age was 68{+/-}15 years, 35% were women), 5% had a first-line AV graft. Patients with AV graft had an 11%-higher weighted hazard of all-cause hospitalization (95% CI 1.09 to 1.13), 16% higher weighted hazard of cardiovascular (95% CI 1.05 to 1.29) and infection-related (95% CI 1.01 to 1.33) hospitalization, 34% higher weighted hazard of vascular access-related hospitalization, and a 9%-higher weighted hazard of all-cause death (95% CI 0.97 to 1.23). Results were consistent for most subgroups, except that the highest hazard of hospitalization with AV graft was blunted in patients with comorbidities (i.e. diabetes, weighted HR of all-cause hospitalization 1.03, 95% CI 0.95-1.12).- To conclude, in patients starting hemodialysis with a catheter, first-line AV graft is associated with increased hazard of hospitalization vs. patients with AV fistula. This may, however, not be the case for patients with a poor vascular condition, i.e., those with diabetes, who have a similar hospitalization and mortality rates with either graft or fistula.

BackgroundPatient activation, defined as the knowledge, skills, and confidence to manage ones health, is associated with better outcomes in chronic disease. However, evidence on interventions that improve activation in people with end-stage kidney disease on hemodialysis remains limited. Methods and analysisThis single-centre, prospective, participant-blinded, randomised controlled trial conducted with adults undergoing chronic hemodialysis in an acute dialysis unit tests the hypothesis that adding tailored activation interventions to usual care improves patient activation and reduces complications in hemodialysis patients compared to usual care alone. A target sample size of 140 patients was recruited and randomised to iPAD interventions or usual care in a 1:1 ratio with an expected intervention period of at least 6 months. The primary outcome of iPAD was change in patient activation from baseline to 18 months. Ethics and disseminationThis study has been approved by all institutional ethics review boards involved in the study. Participants could only be enrolled following informed written consent. Results will be published in peer-reviewed journals and presented at scientific and clinical conferences. ConclusionRecruitment and enrolment targets were successfully achieved, with the cohort broadly representative of the dialysis population, including strong participation from culturally and linguistically diverse and socioeconomically disadvantaged groups. The careful planning and successful execution of the study in resource-constrained environments highlight its feasibility and flexibility, establishing it as a scalable and cost-efficient model for broad implementation in dialysis care globally.

Background and hypothesis.The increased anxiety owing to the COVID-19 pandemic has been suggested to contribute to unhealthy lifestyles and depression in patients undergoing haemodialysis (HD). Therefore, this study aimed to evaluate the degree of fear of COVID-19 after vaccination dissemination and the independent impact of high-order health literacy (HL) on fear, which have not been adequately investigated. Methods.This multicentre cross-sectional study, conducted in 2022, after the widespread availability of the COVID-19 vaccination in Japan, included adults undergoing in-centre HD. Multidimensional HL was measured using the 14-item Functional, Communicative, and Critical Health Literacy Scale. Fear of COVID-19 was measured using the 7-item Japanese version of the Fear of COVID-19 Scale. COVID-19 fear scores in patients with HD were compared with scores of adults in April 2020 (the beginning of the pandemic) using an unpaired t-test. The association between multidimensional HL and COVID-19 fear scores was estimated using a multivariable-adjusted general linear model. Results.A total of 446 patients were analysed, of whom 431 (97%) and nine (2%) received three and two doses of vaccination, respectively. Their COVID-19 fear scores were significantly lower than those of the general population at the beginning of the pandemic (p < 0.001; mean difference -4.4 [95% confidence interval (CI): -5.1 - -3.7]; standardised effect size [ES] 0.77). Higher functional HL was associated with less fear (per 1-pt higher: -2.8 [95% CI: -1.7 - -0.3]; standardised ES -0.51), whereas higher critical HL was associated with greater fear (per 1-pt higher: 3.2 [95% CI: 0.7 - 3.0]; standardised ES 0.80). Communicative HL was not associated with fear. Conclusion.Patients fear of low-functional HL, despite widespread vaccination, can be reduced by providing health information in an easy-to-understand manner. Thus, the fear of sceptics owing to excessive critical HL and honest explanations by healthcare providers may be important. Key learning points What was knownHeightened anxiety stemming from the COVID-19 pandemic exacerbates unhealthy lifestyles and depression, particularly in patients undergoing haemodialysis. Health literacy plays a crucial role in individuals with kidney disease and may mitigate anxiety. Comprehensive data on whether multidimensional health literacy (functional, critical, and communicative) independently correlates with fear of COVID-19, particularly in the context of patients undergoing haemodialysis are lacking. This study addsCOVID-19 fear scores were notably lower in patients undergoing haemodialysis who received the COVID-19 vaccination than in the general population at the onset of the pandemic. Elevated functional health literacy correlated with reduced fear, whereas higher critical health literacy was linked to increased fear. Potential impactFear among individuals with low functional health literacy can be alleviated by delivering health information in a clear and accessible manner, whereas transparent and honest communication from healthcare providers is crucial for patients with heightened fear owing to critical health literacy, who may be sceptical of accurate information.

Rationale & ObjectiveDisparities in home dialysis therapy (HT) use may stem from the interplay between dialysis centre services and patient characteristics. We analysed how these factors directly and indirectly affect HT uptake in England. Study designLinked UK Renal Registry (UKRR) cohort to a national survey of renal centres informed by ethnographic observation. Setting & ParticipantsAdults who initiated kidney replacement therapy (KRT) between 2015 and 2019 at 51 English renal centres, totalling 32,400 individuals identified through the UKRR, with centre practices captured from a 2022 national survey. Exposures or predictorsPatient- and centre-level factors OutcomesUse of HT (home haemodialysis or peritoneal dialysis) within one year of starting KRT. Analytical ApproachSequences of regressions, an extension of path analysis, were used to examine the direct and indirect associations between patient- and centre-level factors and the probability of HT uptake. ResultsDirect associations revealed that both centre- and patient-factors significantly influenced the probability of HT uptake. Patients at centres conducting quality improvement projects, (OR [95% CI]) 1.94, [1.36-2.76]), offering assisted PD (1.89, [1.39-2.57]), fostering staff research engagement (1.35, [1.03-1.77]) or hosting HT roadshows (1.22, [1.05-1.41]) had higher odds of HT uptake. Centres with staff capacity stress had lower uptake (0.60, [0.45-0.81]). Patients on transplant lists at KRT start (2.55, [2.35-2.77]) or living further from a treatment centre (1.10, [1.08-1.12] per 10km) had higher odds of HT uptake. Patients from more deprived areas or minority ethnic groups had lower HT uptake. However, an indirect association was observed through centre practices, as certain centres serving ethnically diverse populations implemented practices that directly increased HT uptake, potentially mitigating disparities. LimitationsHealthcare professional-reported and aggregated survey data ConclusionsThis study identified modifiable centre-level factors that could improve equity in HT access and uptake by mitigating ethnic and area-level disparities in diverse populations.

BackgroundThe effect of dialysis modality on the survival of end-stage renal disease patients is a major public health interest. MethodsIn this retrospective cohort study, all adult end-stage renal disease patients receiving dialysis treatment in Sabah between January 1, 2007 and December 31, 2017 as identified from the Malaysian Dialysis and Transplant Registry were evaluated and followed up through December 31, 2018. The endpoint was all-cause mortality. The observation time was defined as the time from the date of dialysis initiation after the onset of end-stage renal disease to whichever of the following that came first: date of death, date of transplantation, date of last follow-up, date of recovered kidney function, or December 31, 2018. Weighted Cox regression was used to estimate the effect of dialysis modality. Analyses were restricted to patients with complete data on all variables. Results1,837 patients began hemodialysis and 156 patients started with peritoneal dialysis, yielding 7,548.10 (potential median 5.48 years/person) and 747.98 (potential median 5.68 years/person) person-years of observation. 3.1% of patients were lost to follow-up. The median survival time was 5.8 years (95% confidence interval: 5.4, 6.3) among patients who started on hemodialysis and 7.0 years (95% confidence interval: 5.9, indeterminate) among those who started on peritoneal dialysis. The effect of dialysis modality was not significant after controlling for confounders. The average hazard ratio was 0.80 (95% confidence interval: 0.61, 1.05) with hemodialysis as a reference. ConclusionThere was no evidence of a difference in mortality between hemodialysis and peritoneal dialysis.

BackgroundChronic kidney disease (CKD) represents a growing public health challenge worldwide, particularly in low- and middle-income countries. In Brazil, where most patients with end-stage renal disease (ESRD) depend on the public healthcare system for dialysis and transplantation, ensuring adequate vascular access - among the options arteriovenous fistula (AVF) - is critical to sustaining treatment. Despite its clinical relevance, comprehensive national data on vascular access patterns across both public and private sectors have been historically limited. ObjectiveThis study aimed to examine trends in AVF confection for hemodialysis across Brazil from 2015 to 2023, assessing differences in frequency, geographic distribution and sectorial disparities between the public and the private healthcare sector. MethodsA retrospective population-based analysis was conducted using anonymized data from national administrative databases: DATASUS (public sector) and D-TISS (private sector). The majority of AVF confection procedures were included. Statistical analyses considered regional adjustments and were performed using SPSS v.20, with significance set at p < 0.001. ResultsOver the nine-year period, 376.383 AVF procedures were recorded, with 90,57% occurring in the public sector. While the absolute number of AVF confectioners increased, the ratio of AVFs per 1,000 dialysis patients showed a declining trend. Regional disparities were evident, with the Southeast and South regions presenting higher procedure rates compared to other areas. The private sector consistently reported lower confection rates. ConclusionAlthough, separately, dialysis and AVFs rates have risen steadily in Brazil, the relative rate between than has decreasing trend over the years. The predominance of AVF procedures in the public system maintains higher when compared with the private sector.

BackgroundOrthostatic hypotension (OH) is prevalent among dialysis patients and is a known cardiovascular (CV) risk factor. Beta-blockers (BBs) are commonly prescribed to mitigate CV mortality in this population, despite potential risks associated with OH. This study examines the impact of BBs on CV mortality among dialysis patients with OH. MethodsWe conducted a prospective analysis of 134 dialysis patients from the PRECADIA program at the Centro de Educacion Medica e Investigaciones Clinicas (CEMIC), focusing on hemodynamic assessments including blood pressure changes from supine to standing positions, and evaluating CV mortality over a 3-year follow-up. OH was defined by a decrease of [&ge;]10 mmHg in diastolic blood pressure or [&ge;]20 mmHg in systolic blood pressure upon standing. Cox regression analyses were utilized to identify independent predictors of CV mortality. ResultsOf the patients, 23.1% were identified with OH. No significant differences in demographic or baseline clinical characteristics were observed between patients with and without OH, except for a higher diabetes prevalence in the OH group. OH patients treated with BBs demonstrated significantly higher CV mortality (29.6%) compared to those not receiving BBs. Independent predictors of CV mortality included age, time on dialysis, and BB use, with BBs significantly associated with increased CV mortality risk. ConclusionsDialysis patients with OH exhibit a high CV mortality rate, significantly influenced by BB usage. While BBs are recommended for managing CV risks in dialysis patients, their association with increased CV mortality in patients with OH necessitates careful consideration and management strategies.

The COVID-19 pandemic created an unprecedented strain on hospitals in New York City. Although practitioners focused on the pulmonary devastation, resources for the provision of dialysis proved to be more constrained. To deal with these shortfalls, NYC Health and Hospitals/Bellevue, NYU Brooklyn, NYU Medical Center and the New York Harbor VA Healthcare System, put together a plan to offset the anticipated increased needs for kidney replacement therapy. Prior to the pandemic, peritoneal dialysis was not used for acute kidney injury at Bellevue Hospital. We were able to rapidly establish an acute peritoneal dialysis program at Bellevue Hospital for acute kidney injury patients in the intensive care unit. A dedicated surgery team was assembled to work with the nephrologists for bedside placement of the peritoneal dialysis catheters. A multi-disciplinary team was trained by the lead nephrologist to deliver peritoneal dialysis in the intensive care unit. Between April 8, 2020 and May 8, 2020, 39 peritoneal dialysis catheters were placed at Bellevue Hospital. 38 patients were successfully started on peritoneal dialysis. As of June 10, 2020, 16 patients recovered renal function. One end stage kidney disease patient was converted to peritoneal dialysis and was discharged. One catheter was poorly functioning, and the patient was changed to hemodialysis before recovering renal function. There were no episodes of peritonitis and nine incidents of minor leaking, which resolved. Some patients received successful peritoneal dialysis while being ventilated in the prone position. In summary, despite severe shortages of staff, supplies and dialysis machines during the COVID-19 pandemic, we were able to rapidly implement a de novo peritoneal dialysis program which enabled provision of adequate kidney replacement therapy to all admitted patients who needed it. Our experience is a model for the use of acute peritoneal dialysis in crisis situations.

BackgroundIn chronic kidney disease (CKD), patients adherence to prescriptions for diet and for medications might depend on the degree to which they have hope that they will enjoy life, and that hope could vary with the stage of CKD. The aims of this study were to quantify both the association of CKD stage with health-related hope (HR-Hope), and the association of that hope with psychological and physiological manifestations of adherence. MethodsThis was a cross-sectional study involving 461 adult CKD patients, some of whom were receiving dialysis. The main exposure was HR-Hope, measured using a recently-developed 18-item scale. The outcomes were perceived burden of fluid restriction and of diet restriction, measured using the KDQOL, and physiological manifestations of adherence (systolic and diastolic blood pressure [BP], and serum phosphorus and potassium levels). General linear models and generalized ordered logit models were fit. ResultsParticipants at non-dialysis stage 4 and those at stage 5 had lower HR-Hope scores than did those at stage 2 or 3 (combined). Those at non-dialysis stage 5 had the lowest scores. HR-Hope scores of participants at stage 5D were similar to those of participants at stage 4, but they were lower than the scores of participants at stage 2 or 3 (combined). Higher HR-Hope scores were associated with lower perceived burdens of fluid restriction and of diet restriction (adjusted ORs per ten-point difference were 0.82 and 0.84, respectively). Higher HR-Hope scores were associated with lower systolic BP (adjusted mean difference in systolic BP per ten-point difference in HR-Hope scores was -1.87 mmHg). In contrast, HR-Hope scores were not associated with diastolic BP, serum phosphorus levels, or serum potassium levels. ConclusionsAmong CKD patients, HR-Hope is associated with disease stage, with psychological burden, and with some physiological manifestations of adherence.

BackgroundChronic kidney disease (CKD) is associated with an increased risk for cardiovascular events, hospitalizations or mortality. In populations aged [&ge;]40 years, CKD is as prevalent as diabetes or coronary heart disease. Awareness for CKD though is generally low in public, patients and physicians, which hinders early diagnosis and treatment to decelerate disease progress. MethodWe analyzed baseline data collected in 2010 from 3,334 participants with CKD stages 1-5 from German CKD cohorts and registries. CKD unawareness and 95%-confidence intervals (CI) was estimated according to patients answer to the question whether they had ever been told to suffer from a CKD. Prevalence ratios (PR) with 95%-CI were estimated in categories of age, sex, CKD stages, BMI, hypertension, diabetes and other relevant comorbidities. ResultsCKD unawareness was high, reaching 82% (95% CI: 80%-84%) for CKD stages 1 or 2, 71% (68%-73%) in CKD 3a, 49% (45%-54%) in CKD 3b and still 30% (24%-36%) in CKD4, in each stage increasing with age. CKD unawareness was similarly high in patients with hypertension, diabetes or cardiovascular comorbidities. Women were more often unaware than men (PR=1.07 (1.02;1.12)), this sex difference increased with increasing CKD stage. Macroalbuminuria (PR=0.90 (0.82; 1.00)), anemia (PR=0.78 (0.73; 0.83)) and BMI [&ge;]40 (PR=0.88 (0.77; 1.00)) were associated with higher CKD awareness. ConclusionEven in older patients or in patients with comorbidities, CKD unawareness was high. Sex differences were largest in later stages. Guideline oriented treatment of patients with hypertension or diabetes could increase awareness. Patient-physician communication about CKD might be amendable.

BackgroundThis study presents two simulation modelling tools to support the organisation of networks of dialysis services during the COVID-19 pandemic. These tools were developed to support renal services in the South of England (the Wessex region caring for 650 patients), but are applicable elsewhere. MethodsA discrete-event simulation was used to model a worst case spread of COVID-19 (80% infected over three months), to stress-test plans for dialysis provision throughout the COVID-19 outbreak. We investigated the ability of the system to manage the mix of COVID-19 positive and negative patients, and examined the likely effects on patients, outpatient workloads across all units, and inpatient workload at the centralised COVID-positive inpatient unit. A second Monte-Carlo vehicle routing model estimated the feasibility of patient transport plans and relaxing the current policy of single COVID-19 patient transport to allow up to four infected patients at a time. ResultsIf current outpatient capacity is maintained there is sufficient capacity in the South of England to keep COVID-19 negative/recovered and positive patients in separate sessions, but rapid reallocation of patients may be needed (as sessions are cleared of negative/recovered patients to enable that session to be dedicated to positive patients). Outpatient COVID-19 cases will spillover to a secondary site while other sites will experience a reduction in workload. The primary site chosen to manage infected patients will experience a significant increase in outpatients and in-patients. At the peak of infection, it is predicted there will be up to 140 COVID-19 positive patients with 40 to 90 of these as inpatients, likely breaching current inpatient capacity (and possibly leading to a need for temporary movement of dialysis equipment). Patient transport services will also come under considerable pressure. If patient transport operates on a policy of one positive patient at a time, and two-way transport is needed, a likely scenario estimates 80 ambulance drive time hours per day (not including fixed drop-off and ambulance cleaning times). Relaxing policies on individual patient transport to 2-4 patients per trip can save 40-60% of drive time. In mixed urban/rural geographies steps may need to be taken to temporarily accommodate renal COVID-19 positive patients closer to treatment facilities. ConclusionsDiscrete-event simulation simulation and Monte-Carlo vehicle routing model provides a useful method for stress-testing inpatient and outpatient clinical systems prior to peak COVID-19 workloads.