Patient experiences and preferences on short daily and nocturnal home hemodialysis

Quotidian/intensive hemodialysis (short daily and nocturnal) has variable effects on health‐related quality of life (HRQOL) as measured by standard HRQOL tools. We sought to understand the perceived benefits and limitations of quotidian dialysis by interviewing patients who had switched from conventional to home quotidian dialysis. We used a qualitative, phenomenological approach to explore the perceived benefits of quotidian dialysis from 10 patients using either short daily or nocturnal hemodialysis at a tertiary health care center in London, Canada. The patients varied in gender, age, employment status, home support, physical capacity, primary cause of kidney disease, previous forms of renal replacement therapy, and level of education. Four major themes emerged: (1) improvement in physical and mental well‐being including better blood pressure and concentration, (2) increased control over patient's own life including time availability, choosing when to dialyze, and dialyzing at home, (3) decreased perception of being sick including returning to regular employment and avoiding sicker patients who must have in‐center dialysis, and (4) identification of the competencies and supports required for quotidian dialysis including ability to provide self‐care, supportive family, and medical support. Our findings suggest when patients' willingness and physical ability to use quotidian dialysis are coupled with education and support systems to assist patients' and families' self‐directed care, patients qualitatively perceive benefits of both increased physical and mental health, both measures of health‐related quality of life.     

In‐center hemodialysis attendance: Patient perceptions of risks,barriers, and recommendations

Missed hemodialysis treatments lead to increased morbidity and mortality in the end‐stage renal disease population. Little is known about why patients have difficulty attending their scheduled in‐center dialysis treatments. Semistructured interviews with 15 adherent and 15 nonadherent hemodialysis patients were conducted to determine patients' attitudes about dialysis, health beliefs and risk perception regarding missed treatments, barriers and facilitators to hemodialysis attendance, and recommendations to improve the system to facilitate dialysis attendance. Average time on dialysis was 2.5 years for the nonadherent group and 7.3 years in the adherent group. In both groups, patients felt that dialysis is life‐saving and a necessity. A substantial number of patients in both groups understood that missing hemodialysis treatments is dangerous and several patients could clearly communicate the risk of skipping. The most common barriers to hemodialysis were inadequate or unreliable transportation (mentioned in both groups) and a lack of motivation to get to dialysis or that dialysis is not a priority (typically mentioned by the nonadherent group). Facilitators to hemodialysis attendance included explanations from the health care team regarding the risk of skipping and relationships with other dialysis patients. Patient recommendations to improve dialysis attendance included continued education about the risk of poor attendance and more accessible transportation. Patients did not feel that home dialysis would improve adherence. Hemodialysis patients must adhere to a complex and burdensome regimen. Through the elucidation of barriers and facilitators to hemodialysis attendance and through specific patient recommendations, at least three interventions may be further investigated to improve hemodialysis attendance: Improvement of the transportation system, education and supportive encouragement from the health care team, and peer support mentorship.     

Understanding barriers to home‐based and self‐care in‐center hemodialysis

Despite superior outcomes and lower associated costs, relatively few patients with end‐stage renal disease undergo self‐care or home hemodialysis. Few studies have examined patient‐ and physician‐specific barriers to self‐care and home hemodialysis in the modern era. The degree to which innovative technology might facilitate the adoption of these modalities is unknown. We surveyed 250 patients receiving in‐center hemodialysis and 51 board‐certified nephrologists to identify key barriers to adoption of self‐care and home hemodialysis. Overall, 172 (69%) patients reported that they were “likely” or “very likely” to consider self‐care hemodialysis if they were properly trained on a new hemodialysis system designed for self‐care or home use. Nephrologists believed that patients were capable of performing many dialysis‐relevant tasks, including: weighing themselves (98%), wiping down the chair and machine (84%), clearing alarms during treatment (53%), taking vital signs (46%), and cannulating vascular access (41%), but thought that patients would be willing to do the same in only 69%, 34%, 31%, 29%, and 16%, respectively. Reasons that nephrologists believe patients are hesitant to pursue self‐care or home hemodialysis do not correspond in parallel or by priority to reasons reported by patients. Self‐care and home hemodialysis offer several advantages to patients and dialysis providers. Overcoming real and perceived barriers with new technology, education and coordinated care will be required for these modalities to gain traction in the coming years.     

The integrated management for renal replacement therapy in Portugal

Portugal was the first European country to introduce an integrated management of end‐stage renal disease (IM ESRD). This new program integrates various dialysis services and products, which are reimbursed at a fixed rate/patient/week called “comprehensive price payment.” This initiative restructured the delivery of dialysis services, the monitoring of outcomes, and the funding of renal replacement therapy. This article described the implementation of a new model of comprehensive provision of hemodialysis (HD) services and aimed to assess its impact on dialysis care. Quality assessments and reports of patient satisfaction, produced by the Ministry of Health since 2008, as well as national registries and reports, provided the data for this review. Indicators of HD services in all continental facilities show positive results that have successively improved along the period of 2009–2011, in spite of an average annual growth of 3% of the population under HD treatment. Mortality rates for HD patients were 12.7%, 12%, and 11%, respectively in 2009, 2010, and 2011; annual hospitalization rates were 4.9%, 3.8%, and 4.4% for the same years; key performance indicators showed averages above the reference values such as hemoglobin, serum phosphorus, eKt/V, water quality, number of days of hospitalization per patient per year, and number of weekly dialysis sessions. The financing analysis of IM ESRD demonstrates a sustained control of global costs, without compromising quality. The IM ERSD program is an innovative and quality‐driven approach that benefits both dialysis patients and providers, contributing toward the rationalization of service provision and the efficient use of resources.     

Free dialysis in Nepal: Logistical challenges explored

Nepal's Ministry of Health began offering free lifetime hemodialysis (HD) in 2016. There has been a large growth in renal replacement therapy (RRT) services offered in Nepal since 2010, when the last known data on the subject was published. In 2016, 42 HD centers existed (223% increase since 2010) serving 1975 end stage renal disease patients (303% increase since 2010); 36 nephrologists were registered (200% increase since 2010), 12 were trained in transplantation, and 790 transplants had been performed to date. We estimate the incidence of end stage renal disease to be 2900 patients (100 per million population). With an annual cost of approximately US$2300 per dialysis patient, offering free dialysis could potentially cost the government US$6.7 million per year, suggesting that 2.1% of the annual health budget would be allocated to 0.01% of the population. The geographic zone surrounding the capital city, Kathmandu, contains 50% of HD centers, but only 14.5% of Nepal's population. Forty‐eight percent of the population lives within zones without HD service, therefore infrastructure challenges exist in providing equitable access to RRT. The aim of this article is to summarize the current statistics of RRT in Nepal.     

Hospital-Based Nocturnal Hemodialysis—A Novel Approach to Solving Old Problems

In early 2003, cases of SARS had surfaced around the world. The vast majority happened in China, Hong Kong, and Canada. In Toronto, the individual who manifested symptoms of SARS after visiting China died on March 22, 2003. A few days later SARS was declared a provincial emergency. Corona virus, the causative agent, is not well known. Its transmission and mutation had to be researched. Shortly thereafter, clusters of people were showing symptoms of the virus. There were 258 probable cases of SARS by May 14. The Ontario Ministry of Health and health care providers took steps to contain the virus, isolating those who were exposed and adopting new infection control procedures. On May 17, the provincial emergency was lifted. On May 25, there was a new wave of SARS cases (2nd outbreak). This was traced back to an RN who worked in a non‐SARS unit. Nurses working directly with SARS were faced with very challenging times. SARS was a huge concern and impacted all health care professionals. The hemodialysis unit was no exception. After all, dialysis patients are already immunocompromised, mostly elderly, and frequent visits to the hospital make them more susceptible to the virus. Objective: To identify how hemodialysis nurses were impacted by the SARS outbreak and the nursing management to control the disease. Method: Saint Michael's Hospital in Toronto took a leadership role and became one of the SARS Tertiary Response Team. Four hemodialysis nurses were designated as trainers to train the other staff regarding infection prevention and control. Measures were in place such as: (a) strict screening methods for patients, staff, and visitors; (b) mask fitting for all staff; (c) use of PPE (protective protection equipment) (d) use of Hospital ID bar code for staff to declare themselves free of SARS. Results/Conclusion: On August 25, there was only one probable case and there was no evidence of transmission of the virus in the hemodialysis unit. As for the nurses and all the unsung heroes who always put the needs and safety of their patients ahead of themselves, they continue to be dedicated in maintaining quality patient care even in the face of crisis or in an environment of fear.     

Is home hemodialysis a practical option for older people?

An increasing demand for in-center dialysis services has been largely driven by a rapid growth of the older population progressing to end-stage kidney disease. Since the onset of the COVID-19 pandemic, efforts to encourage home-based dialysis options have increased due to risks of infective transmission for patients receiving hemodialysis in center-based units. There are various practical and clinical advantages for patients receiving hemodialysis at home. However, the lack of caregiver support, cognitive and physical impairment, challenges of vascular access, and preparation and training for home hemodialysis (HHD) initiation may present as barriers to successful implementation of HHD in the older dialysis population. Assessment of an older patient's frailty status may help clinicians guide patients when making decisions about HHD. The development of an assisted HHD care delivery model and advancement of telehealth and technology in provision of HHD care may increase accessibility of HHD services for older patients. This review examines these factors and explores current unmet needs and barriers to increasing access, inclusion, and opportunities of HHD for the older dialysis population.     

D‐dimer levels in maintenance hemodialysis patients: High prevalence of positive values also in the group without predisposing diseases

We aimed to estimate the prevalence of elevated D‐dimer levels in all chronic hemodialysis patients and those without additional disease, and to identify factors associated with increased D‐dimer. In 167 chronic hemodialysis patients from our center, D‐dimer was measured before dialysis. The effects of age, C‐reactive protein (CRP), recent acute illness, vascular access, anticoagulation type, dialysis vintage, and chronic diseases, considered to predispose for increased D‐dimer levels, were analyzed. The median D‐dimer in the whole group was 966 (inter‐quartile range [IQR] 524–1947) μg/L and was positive (>500 μg/L) in 75% of cases. D‐dimer was positive in 91% of patients with acute illness, 76% of those with predisposing chronic diseases, but was still positive in 52% of patients without additional disease (i.e., acute illness or predisposing chronic diseases) – median D‐dimer was 538.5 (IQR 359–966) μg/L. D‐dimer was correlated to patients' age, but not dialysis vintage. In univariate analysis, the D‐dimer levels were significantly higher in patients with atrial fibrillation, ischemic heart disease, recent acute illness, increased CRP, dialyzed over a catheter, and on citrate anticoagulation. Multivariate logistic regression showed that only age >65 years (odds ratio [OR] 2.93), catheter (OR 4.86), and positive CRP (OR 4.07) were independently associated with positive D‐dimer at 500 μg/L cut‐off, while the significance of age disappeared at 2000 μg/L cut‐off. To conclude, the high prevalence of positive D‐dimer values even in hemodialysis patients without additional disease limits the use of D‐dimer for exclusion of thromboembolic diseases in hemodialysis patients.     

Renal replacement therapy in Nepal

Renal replacement therapy in Nepal fulfills only a small part of the current needs, with 97 hemodialysis machines available for the general population of 29 million. Transportation difficulties to dialysis centers preclude many of the patients from end-stage renal disease care, due to the rural nature of the population. Peritoneal dialysis (PD) organized into rural sub segments, considering the Mexican model of PD and government funding appear to offer some solution to provision of care for this mountainous rural country. We review the current statistics of dialysis patients, hemodialysis numbers, and renal transplantations within Nepal and offer suggestions regarding possibilities for increasing renal care within the country.     

Role of bicarbonate dialysis in prevention of serious arrhythmias in high‐risk cardiac patients undergoing regular hemodialysis

Background: Cardiac arrhythmias are considered as one of the most important causes of mortality in patients on hemodialysis. Arrhythmias frequently occur in patients with chronic renal failure on regular hemodialysis with reported incidences varying from 30–48% of patients. These abnormalities can span from supraventricular to severe ventricular arrhythmia. There is an increased frequency of occurrence and clustering of arrhythmias around the dialysis time. Aim of the study: To detect the difference between acetate and bicarbonate dialysis as regard to the type and frequency of arrhythmia in those patients. Study design: This study was done on 20 male patients age 51–73, all have history of heart disease. Patients were divided into 2 equal groups using acetate in group 1 and bicarbonate in group 2. All patients were on regular hemodialysis (4 hours, thrice weekly). Careful history and clinical examination were done. Pre‐dialysis investigations included serum creatinine, blood urea nitrogen, serum sodium, potassium, calcium and phosphorus, serum albumin, hemoglobin, and arterial blood gases. Post‐dialysis serum potassium and arterial blood gases were measured. ECG and forty‐eight hours ambulatory monitor (Holter monitor)(before, during, and after hemodialysis, till the end of the dialysis day and throughout the following day) were performed. Results: Group 1 showed significantly less post‐dialysis supraventricular arrhythmias than in dialysis day (210.9 ± 236 and 62.3 ± 14.4), respectively. Significantly less ventricular arrhythmias in post‐dialysis than in dialysis day (30.7 ± 50.4, and 106.2 ± 128.4), respectively. While in Group 2 there were insignificant differences regarding supraventricular arrhythmias (21.9 ± 28.9 and 16.6 ± 36.3) and ventricular arrhythmias (22.9 + 7.8 and 29.6 + 12.8) in dialysis day than in post‐dialysis day. There was significantly higher frequency of supraventricular and ventricular arrhythmias in the dialysis day in acetate hemodialysis in comparison to bicarbonate hemodialysis. Conclusion: Bicarbonate hemodialysis is less arrhythmogenic in comparison to acetate hemodialysis and has better effect on the blood pH and greater degree of base repletion. Continuous ambulatory ECG recording (Holter) is a useful tool in detecting arrhythmias in dialysis patients.     

Inappropriately elevated endothelin‐1 plays a role in the pathogenesis of intradialytic hypertension

The aim of this study is to investigate the effects of endogenous vasoactive substances on the occurrence of intradialytic hypertension (IDH) in patients during maintenance hemodialysis. Thirty‐four maintenance hemodialysis patients were enrolled in this trial, and 17 of them were diagnosed with IDH (defined as an increase in blood pressure of at least 10 mmHg during or immediately after a hemodialysis session), while 17 age‐matched and sex‐matched controls without IDH were selected for a retrospective comparison. We collected patients' blood samples before and after a dialysis session and measured the plasma levels of N‐terminal fragment brain natriuretic peptide, renin, angiotensin‐II, aldosterone (ALD), angiotensin‐converting enzyme (ACE), endothelin‐1 (ET‐1), nitric oxide (NO), norepinephrine (NOR), and adrenomedullin. The post‐dialysis serum ET‐1 concentrations were significantly higher (4.09 ± 2.06 vs. 2.75 ± 1.34 pg/mL, P < 0.05), while the post‐dialysis ratio of NO to ET‐1 was lower (17.79 ± 5.65 vs. 24.78 ± 12.04, P < 0.05) in IDH patients compared with the control group. Post‐dialysis ALD and NOR values were significantly lower (P < 0.01) and ACE levels were significantly higher (P < 0.01) than the pre‐dialysis concentrations only in the control and not in the IDH group. All other measured factors did not differ significantly between the groups and between pre‐dialysis and post‐dialysis determinations. Compared with blood angiotensin‐II, ALD, ACE, NOR, adrenomedullin, N‐terminal fragment brain natriuretic peptide, and NO status, inappropriately elevated ET‐1 plasma concentrations may play a predominant role in the pathogenesis of IDH.     

Comparison of Preventive Care Provided to Dialysis Patients by Nephrologists and to Patients Followed in General Medical Clinics: Compliance with American College of Physicians Guidelines

Most end‐stage renal disease (ESRD) patients do not have primary‐care providers, and preventive medicine often is provided by their nephrologists. Little has been written about their success in providing this care. We studied all patients on dialysis at our hospital and compared their preventive care to a control group followed in the general medical clinic. The general medical group showed higher compliance with Pap smears (89% vs 48%), mammography (87% vs 62%), fecal occult blood testing (75% vs 50%), and pneumococcal vaccination (55% vs 28%). The ESRD group had better compliance with influenza vaccination (70% vs 55%) and lipid profile (100% vs 75%). When the subgroup of patients on hemodialysis (HD) was compared with patients on peritoneal dialysis (PD), it was shown that HD patients were more likely than PD patients to receive preventive care. We also compared diabetes‐specific care. The ESRD group had a higher rate of HbA _1C (100% vs 78%) and lipid monitoring (100% vs 76%), diabetes education (100% vs 84%), and podiatry visits (70% vs 38%). There was no difference in ophthalmologic examination or influenza vaccination. We found that nephrologists provide preventive care to ESRD patients with success approximately equal to primary‐care physicians in our institution, although in different parameters. Ready access to dialysis patients and their blood and unit‐specific policies contribute to compliance that is above national averages. Further improvements can be made by additional preventative measures policies, by physician and patient education, and by monitoring primary‐care compliance in the chart.     

Heparin Use in Daily Hemodialysis

More frequent dialysis is thought to be associated with increased heparin requirements; however, limited data are available which compare heparin requirements of conventional to daily dialysis. Objectives: To determine differences in heparin dose during conventional thrice‐weekly dialysis (CHD) compared to daily hemodialysis (DHD). Methods: All patients within the daily home hemodialysis at the Northwest Kidney Centers were evaluated for heparin dose both pre‐ and post initiation of daily hemodialysis. Patients on DHD received an initial bolus of heparin, without a continuous heparin drip, and supplemental heparin midway through the dialysis run as needed to maintain adequate activated clotting times (ACTs). CHD patients received a heparin bolus, followed by initiation of heparin drip as needed to maintain adequate ACTs. Results: Of the 1117 patients who dialyze at the NKC, 55% were Caucasian, 21% African‐American, 20% Asian/Pacific Islander, and 35% were of other ethnicity. The majority of patients were greater than 60 years (56%), while 36% ranged from 40–60 years and 13% ranged from 20–40 years. Male patients constituted 54% of patients. Diabetes was the primary cause of renal disease (36%), followed by hypertension (21%) and glomerular disease (18%). Of those patients in the home hemodialysis program (n = 45), 10 patients started daily home hemodialysis using the Aksys daily home hemodialysis system. Of those, the majority was male (100%), Caucasian (78.8%) with an average age of 46.7 ± 18 years. Glomerulonephritis was the primary cause of end‐stage renal disease (40%), while the percentages of other diseases were similar [Alport's syndrome (20%), hypertension (20%) and diabetes (10%)]. Compared to initial DHD heparin requirements (10,111 ± 2219 units), CHD heparin dose requirements (6833 ± 2715 units) were significantly lower (p = 0.045); however, total heparin needs were similar between groups (10,166 ± 4380 units vs. 10,778 ± 2959 units) (p = 0.324). Conclusion: Although patients initiating DHD have greater initial heparin requirements than when on CHD, total heparin doses remain similar to those required on conventional thrice‐weekly hemodialysis. Greater initial heparin doses required during short daily dialysis appear safe compared to those of conventional dialysis.