The perspectives of Aboriginal patients and their health care providers on improving the quality of hemodialysis services: A qualitative study

Chronic kidney disease has a higher prevalence in Indigenous populations globally. The incidence of end‐stage kidney disease in Australian Aboriginal people is eight times higher than non‐Aboriginal Australians. Providing services to rural and remote Aboriginal people with chronic disease is challenging because of access and cultural differences. This study aims to describe and analyze the perspectives of Aboriginal patients' and health care providers' experience of renal services, to inform service improvement for rural Aboriginal hemodialysis patients. We conducted a thematic analysis of interviews with Aboriginal patients (n = 18) receiving hemodialysis in rural Australia and health care providers involved in their care (n = 29). An overarching theme of avoiding the “costly” crisis encompassed four subthemes: (1) Engaging patients earlier (prevent late diagnosis, slow disease progression); (2) flexible family‐focused care (early engagement of family, flexibility to facilitate family and cultural obligations); (3) managing fear of mainstream services (originating in family dialysis experiences and previous racism when engaging with government organizations); (4) service provision shaped by culture (increased home dialysis, Aboriginal support and Aboriginal‐led cultural education). Patients and health care providers believe service redesign is required to meet the needs of Aboriginal hemodialysis patients. Participants identified early screening and improving the relationship of Aboriginal people with health systems would reduce crisis entry to hemodialysis. These strategies alongside improving the cultural competence of staff would reduce patients' fear of mainstream services, decrease the current emotional and family costs of care, and increase efficiency of health expenditure on a challenging and increasingly unsustainable treatment system.     

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.     

Psychological Symptoms Are Greater in Caregivers of Patients on Hemodialysis Than Those of Peritoneal Dialysis

Background: The purpose of this study was to evaluate and compare psychosocial characteristics in caregiving relatives (caregivers) of hemodialysis (HD) and peritoneal dialysis (PD) patients. Methods: Thirty‐three caregivers (17 women, 16 men) of HD patients, 27 caregivers (11 women, 16 men) of PD patients, and a control group of 49 subjects who do not care for family members with chronic illness (23 women, 26 men) are included in this study. The brief symptom inventory (BSI), social disability schedule (SDS), and brief disability questionnaire (BDQ) were used for the psychosocial evaluation. Results: The mean age, men‐to‐women ratios, duration of education, and distribution of marital status did not differ significantly among the three groups. In addition, dialysis duration and distribution of caregiver type were not different between the HD and PD groups. Although the mean global severity index scores of the three groups were similar, somatization and depression scores from BSI subitems were greater in the HD group than the scores of the PD and control groups. Although the mean SDS and BDQ scores were higher in the HD group, the differences did not achieve statistical significance. BSI subitems such as somatization, obsession–compulsion, interpersonal sensitivity, depression, and anxiety were positively correlated among themselves. Hostility and somatization were negatively correlated with age and education, respectively. Nevertheless, somatization was positively correlated with age. Social disability was negatively correlated with duration of education. Conclusion: Somatization and depression are greater in the caregivers of center HD patients compared to PD and control groups. According to the findings of this study, we suggest that caregiving family members of dialysis patients especially on HD also should be evaluated for psychosocial problems and supported as needed. Further studies are needed to explore whether psychosocial parameters of caregivers predict outcomes for caregivers and patients.     

Caregiver burden among nocturnal home hemodialysis patients

Recent studies have suggested improvements in quality of life (QOL) in patients on quotidian dialysis compared with conventional hemodialysis. Few studies have focused on the burden and QOL in caregivers of patients with end-stage renal disease (ESRD) on nocturnal home hemodialysis (NHD). We aim to assess the caregivers' burden, QOL, and depressive symptoms and to compare these parameters with their patients' counterparts. Cross-sectional surveys were sent to 61 prevalent NHD patients and their caregivers. Surveys assessed demographics, general self-perceived health using the 12-Item Short Form Health Survey (SF-12) and the presence of depression using the Beck Depression Inventory. Subjective burden on caregivers was assessed by the Caregiver Burden scale and was compared with perceived burden by the patients. Thirty-six patients and 31 caregivers completed the survey. The majority of caregivers were female (66%), spouse (81%) with no comorbid illness (72%). Their mean age was 51 ± 11 years. Patients were mostly male (64%) with a median ESRD vintage of 60 months (interquartile range [IQR], 18-136 months) and a mean age of 52 ± 10 years. Compared to caregivers, patients had lower perceived physical health score but had similar mental health score. Depression criteria were present in 47% of patients and 25% of caregivers. Total global burden perceived by either caregivers or patients is relatively low. Although there is a relatively low global burden perceived by caregivers and patients undergoing NHD, a significant proportion of both groups fulfilled criteria for depression. Further innovative approaches are needed to support caregivers and patients performing NHD to reduce the intrusion of caring for a chronic illness and the risk of developing depression.     

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.     

Hemodialysis for infants,children, and adolescents

Children with chronic kidney disease stage 5 requiring dialysis can be treated by peritoneal or hemodialysis. In the United Kingdom nearly twice as many children receive peritoneal dialysis compared with hemodialysis. Technical aspects of pediatric hemodialysis are challenging and include the relative size of extracorporeal circuit and child's blood volume, assessment of adequacy,technical and complications of vascular access. Alternatives to standard hospital‐based hemodialysis are also increasingly available. Optimizing nutritional status with the support of specialist pediatric dietitians is key to the management of children receiving hemodialysis. The effects of chronic illness on growth and school achievement, as well as the psychological, emotional, and social development of the child should not be underestimated. This review focuses on the above elements and highlights common pediatric practice in the United Kingdom.     

Insights into nephrologist training, clinical practice, and dialysis choice

There is variable emphasis on dialysis-specific training among US nephrology fellowship programs. Our study objective was to determine the association between nephrology training experience and subsequent clinical practice. We conducted a national survey of clinical nephrologists using a fax-back survey distributed between March 8, 2010 and April 30, 2010 (N = 629). The survey assessed the time distribution of clinical practice, self-assessment of preparedness to provide care for dialysis patients at the time of certification examination, distribution of dialysis modality among patients, and nephrologists' choice of dialysis modality for themselves if their kidneys failed. While respondents spent 28% of their time caring for dialysis patients, 38% recalled not feeling very well prepared to care for dialysis patients when taking the nephrology certification examination. Sixteen percent obtained additional dialysis training after fellowship completion. Only 8% of US dialysis patients use home dialysis; physicians very well prepared to care for dialysis patients at the time of certification or who obtained additional dialysis training were significantly more likely to provide care to home peritoneal dialysis patients. Even though 92% of US dialysis patients receive thrice weekly in-center hemodialysis, only 6% of nephrologists selected this for themselves; selection of therapy for self was associated with dialysis modalities used by their patients. Nephrology training programs need to ensure that all trainees are very well prepared to care for dialysis patients, as this is central to nephrology practice. Utilization of dialysis therapies other than standard hemodialysis is dependent, in part, on training experience.     

Provision and quality of dialysis services in Libya

Dialysis is entirely funded by the public health care sector in Libya. Access to treatment is unrestricted for citizens but there is a lack of local information and no renal registry to gather national data. This cross-sectional study aimed to investigate dialysis provision and practice in Libyan dialysis facilities in 2009. A structured interview regarding dialysis capacity, staffing and methods of assessment of dialysis patients, and infection control measures was conducted with the medical directors of all 40 dialysis centers and 28 centers were visited. A total of 2417 adult patients were receiving maintenance dialysis in 40 centers, giving a population prevalence of approximately 624 per million. Most dialysis units were located in the northern part of the country and only 12.5% were free-standing units. Only three centers offered peritoneal dialysis. One hundred ninety-two hemodialysis rooms hosted 713 functioning hemodialysis stations, giving a ratio of one machine to 3.4 patients. Around half of centers operated only two dialysis shifts per day. Nephrologist/internist to patient ratio was 1:40 and nurse to patient ratio was 1:3.7. We found a wide variation in monitoring of dialysis patients, with dialysis adequacy assessed only in a minority. Separate rooms were allocated for chronic viral infection seropositive patients in 92.5% of the units. In general, the provision of dialysis is adequate but several areas for improvement have been identified, including a need for implementation of guidelines, recruitment of more nephrologists, and the development of more cost-effective alternatives such as peritoneal dialysis and transplantation.     

Is there any interaction of resistin and adiponectin levels with protein‐energy wasting among patients with chronic kidney disease

The aim of this study was to evaluate the effects of adipocytokines including adiponectin, leptin, resistin, neuropeptide Y and ghrelin in chronic kidney disease (CKD) patients on appearance of protein‐energy wasting (PEW). One hundred fifty patients with mean age of 45.4 ± 15.9 years, without active infections or chronic inflammatory conditions were recruited into the study. Study groups were control group (consisting of 30 healthy volunteers with normal kidney functions), hemodialysis group, predialysis group, peritoneal dialysis group and kidney transplant group. Fasting morning serum leptin, ghrelin, acylated ghrelin, neuropeptide Y, adiponectin, resistin levels of all of the groups were measured. Anthropometric and nutritional assessments of all patients were obtained. Diagnosis of PEW was made according to definition recommended by the International Society of Renal Nutrition and Metabolism. Presence of PEW in hemodialysis (23.3%) and peritoneal dialysis (26.7%) groups were significantly higher than those of predialysis (3.3%), and transplantation (0%) groups. Adiponectin and resistin levels in predialysis, peritoneal dialysis and hemodialysis patients were significantly higher than control group (p: 0.0001). This study had given significant positive correlations between presence of PEW and serum resistin (r: 0.267, p: 0.001), and serum adiponectin levels (r: 0.349, p: 0.0001). There were no relationship between presence of PEW and ghrelin, acylated‐ghrelin, neuropeptide Y, and leptin levels of the groups. CKD patients except transplant patients had higher adiponectin and resistin levels than control group. PEW was found to be linearly correlated with resistin and adiponectin. High serum resistin and adiponectin levels might have a role in development of PEW among dialysis patients.     

Sexual function in women receiving maintenance dialysis

While substantial attention has been paid to the issue of sexual dysfunction in men on chronic dialysis, less is known about this problem in women with end-stage renal disease. We sought to assess sexual dysfunction in women on chronic dialysis and determine whether patients discuss this problem with their providers and receive treatment. We prospectively enrolled women receiving chronic hemodialysis or peritoneal dialysis in Pittsburgh, PA. We asked patients to complete the 19-item Female Sexual Function Index (FSFI) to assess sexual function and a 5-item survey that assessed whether patients had discussed sexual dysfunction with their providers and/or received treatment for this problem in the past. We enrolled 66 patients; 59 (89%) on hemodialysis and 7 (11%) on peritoneal dialysis. All patients completed the FSFI, of whom 53 (80%) had FSFI scores <26.55, consistent with the presence of sexual dysfunction. Of 37 patients who were married or residing with a significant other, 27 (73%) had sexual dysfunction. Among 24 participants who reported having been sexually active over the previous 4 weeks, 11 (46%) had sexual dysfunction. Only 21% of patients with sexual dysfunction had discussed this problem with their gynecologist, renal or primary provider, and 3 (6%) reported having received treatment. Sexual dysfunction is common in women on dialysis, even among patients who are married or residing with a significant other and those who are sexually active. However, few women discuss this issue with their providers or receive treatment.     

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.     

Gustatory sweating recurring on peritoneal dialysis but resolving during periods of hemodialysis

Gustatory sweating is a rare disorder characterized by profuse sweating on the forehead, face, scalp, and neck occurring soon after ingesting food, which has been reported in diabetic patients. The mechanism is thought to be triggered by taste buds and not gastric stimulation. We report a case where gustatory sweating repeatedly developed on peritoneal dialysis that resolved on periods of hemodialysis. A 32-year-old woman with diabetic end-stage renal disease developed gustatory sweating shortly after beginning continuous ambulatory peritoneal dialysis despite excellent clearances. After 5 months, she changed to hemodialysis for 2 months and noticed complete resolution of her gustatory sweating; however, after her return to peritoneal dialysis 2 months later, her gustatory sweating recurred. While on peritoneal dialysis, she was treated with clonidine, which resulted in improvement but not resolution of her symptoms as had occurred on hemodialysis. Another period on hemodialysis resulted in the resolution of her symptoms that returned again after restarting peritoneal dialysis. Clonidine provided incomplete relief while topical glycopyrrolate was effective and without complications. We report recurrent gustatory sweating on peritoneal dialysis that resolved with hemodialysis. We have no data to suggest that intra-abdominal stimulation played a role, but rather that despite excellent clearances neuropathy may have played a role. Treatment with topical glycopyrrolate may be safe and effective given every third day if clonidine is ineffective.     

Quality of life, self‐care and sense of coherence in patients on hemodialysis: A comparative study

The number of patients treated for end-stage renal disease increases in Sweden like the rest of the world. During the last six years more than 1000 persons a year started renal replacement therapy. Today hemodialysis patients have the opportunity to choose different treatment modalities—home hemodialysis, self‐care dialysis, or conventional dialysis. Purpose:  The aim of the study was to investigate differences in patient on home hemodialysis, self‐care dialysis, and conventional dialysis regarding quality of life, self‐care, and sense of coherence. Methods:  Questionnaires were used: Short Form (SF‐36), Appraisal of Self‐Care Agency (ASA‐scale), and Sense of Coherence scale (SOC). 19 patients were included in the study (five patients on home hemodialysis, six self‐care patients, and eight patients on conventional dialysis). Results:  The results showed a tendency of higher scores in quality of life, self‐care, and sense of coherence for the home hemodialysis patients. Conclusion:  Since the number of participants in this study was low, it is necessary to include more patients in a future study in order to verify the results.     

Portable and wearable dialysis: where are we now?

Although dialysis is a life-saving treatment for patients with acute and chronic kidney disease, mortality remains high, with the survival of patients treated by regular hemodialysis similar to that of some solid organ tumors. Recent reports have suggested that a major increase in the dose of dialysis, delivered by frequent nocturnal dialysis, may improve survival. Unfortunately, only a minority of centers can offer this type of therapy, and only to a minority of their patients. Thus, to improve access to dialysis as well as increase the delivered dose of dialysis, a major change in the current paradigm of dialysis delivery is required. For many years, the "holy grail" of dialysis has been to develop a wearable or portable system, allowing patients to be treated while performing their normal activities of daily living. It is only recently with the advances in technology that such dialysis devices have been possible. Prototype devices for both hemodialysis and peritoneal dialysis have been studied with favorable results. Typically, these have been short-term studies, and longer term trials are eagerly awaited, to determine whether the current generation of wearable continuous dialysis devices cannot only remove waste products of metabolism and control volume but also maintain acid-base and electrolyte homeostasis and actually improve outcomes. In addition, a novel generation of dialysis devices based on nanotechnologies are being developed. Hopefully, these wearable continuous devices will be available as an option for routine clinical practice in the not-too-distant future.     

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.