Effect of multidisciplinary care of dialysis initiation for outpatients with chronic kidney disease

Incidental AVF creation during unrelated hospitalization is associated with worse outcomes compared with outpatient AVF creation

INTRODUCTION

Arteriovenous fistula (AVF) creation during an inpatient hospitalization is often performed for patient convenience and to ensure compliance. We sought to evaluate whether this approach has comparable outcomes to outpatient AVF creation.

METHODS

We identified patients undergoing index AVF creation from the United States Renal Data System dataset (2012-2017). Patients were grouped into outpatient and inpatient. Outpatient included patients that were operated in either an outpatient setting, ambulatory surgical center or were admitted inpatient on the day of AVF creation. Inpatient included only patients with claims for an inpatient visit before access creation. Multiple safety outcomes were compared between groups using unadjusted and adjusted logistic regression methods generating odds ratios and 95% confidence intervals (95% CI). One-year maturation rates were compared using competing-risks regression methods generating sub-hazard ratios (sHR) and 95% CI. Outcomes were also compared after 1:1 propensity score matching.

RESULTS

We identified 68,872 patients undergoing AVF creation, 4855 (7.1%) of which were created during inpatient hospitalization. Patients in the inpatient group were older (65.8 ± 13.8 vs 65.2 ± 13.8, p = 0.002), more likely to be of Black race (28.1% vs 26.8%, p = 0.02), and have cardiovascular comorbidities (all p < 0.05). Patients in the inpatient groups were more likely to be dialyzed at for-profit (88.1% vs 85.9%, p < 0.01) and freestanding (94.8% vs 92.9%, p < 0.01) dialysis centers. On both unadjusted and adjusted analysis, inpatient group was more likely to experience 30-day adverse events (e.g. pneumonia, COPD exacerbation, stroke, myocardial infarction), any complication, and all-cause mortality. On competing risks analysis, successful two-needle cannulation at 1 year was significantly less likely in the inpatient group (68.1% vs 76.8%, p < 0.01; sHR = 0.68 [95% CI, 0.65-0.71], p < 0.01). These trends were robust on 1:1 propensity matching.

CONCLUSION

Incidental AVF creation in hospitalized patients is associated with worse outcomes, ranging from mortality to postoperative complications to fistula maturation, compared with outpatient AVF creation.

Evaluation of the Virtual Multidisciplinary Team Meeting Model for Adult Patients on Haemodialysis: A Qualitative Study

BACKGROUND

During the COVID-19 pandemic, face-to-face multidisciplinary team meetings evolved to virtual platforms. Healthcare professionals' experiences of virtual multidisciplinary team meetings is unknown, and it is not clear whether virtual meetings are a feasible long-term alternative in the post pandemic era.

OBJECTIVE

To explore the experiences and perceptions of members of the multidisciplinary team managing people with kidney disease regarding virtual meetings.

DESIGN

Semi-structured interviews were conducted. Maximal variation sampling was used to ensure adequate representation by gender and professional roles. All interviews were audiotaped and transcribed verbatim, before being analysed by two researchers independently using the Theoretical Domains Framework. A third researcher was then referred to for resolving any disagreements.

PARTICIPANTS

Members of the nephrology multidisciplinary team meeting.

MEASUREMENTS

Health professionals' experiences and perspectives of virtual multidisciplinary team meetings.

RESULTS

Of the nine participants interviewed, six were females and the majority were nurses. Most of the participants were aged 30-40 years. Three main themes emerged within the three primary domains: impact on staff and patient outcomes; limited technological skills, and opportunities for improvement. From the four intermediate domains, another four themes were captured: professional responsibility; impact on engagement; barriers to participation; and desire to provide optimal patient care.

CONCLUSIONS

Healthcare professionals of a single centre nephrology care team reported that virtual multidisciplinary meetings overcame geographic barriers and infection control restrictions, and offered possibilities for broader inclusivity. However, strategies are needed to overcome technological issues, improve participants' skills to navigate technology, and optimize active participation.

The way home: a scoping review of public health interventions to increase the utilization of home dialysis in chronic kidney disease patients

BACKGROUND

Home 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 effects of public health interventions on the uptake and retention of HoD utilization, including both Peritoneal Dialysis (PD) and Home Hemodialysis (HHD).

METHODS

Relevant 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.

RESULTS

Forty-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.

CONCLUSION

Education 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.

Shared decision-making in selecting modality of renal replacement therapy confers better patient prognosis after the initiation of dialysis

INTRODUCTION

The effect of shared decision-making (SDM) regarding the choice of renal replacement therapy (RRT) for chronic kidney disease (CKD) patients on their mortality after the induction of dialysis therapy has not been adequately investigated.

METHODS

Patients who initiated dialysis at our hospital were divided into two groups according to whether they participated in SDM in the outpatient clinic, and survival analysis was performed. We also examined the effect of SDM in the outpatient clinic on mortality.

RESULTS

Of the 554 patients, 123 (22.2%) were in the SDM group. The survival rate was significantly higher in the SDM group (p = 0.001, log-rank test). Multivariate analysis excluding ADL, which competed with SDM, showed that SDM was significantly associated with mortality (HR 0.593, 95% CI: 0.353-0.997, p = 0.049).

CONCLUSION

SDM regarding RRT selection in the outpatient clinic may be associated with a better patient prognosis after dialysis induction.

Key Performance Indicators of Secondary Health Care in Chronic Kidney Disease: Experience in Public and Private Services in the State of São Paulo, Brazil

Introduction: The objective of this study was to evaluate quality indicators of secondary health care in chronic kidney disease (CKD). Methods: This retrospective longitudinal study was conducted in an outpatient medical nephrology clinic of the Brazilian Unified Health System (UHS) and a multidisciplinary outpatient clinic of a private health plan (PHP). The inclusion criteria were age ≥ 18 years, ≥ 3 medical appointments, and follow-up time ≥ 6 months. Results: Compared to PHP patients (n = 183), UHS patients (n = 276) were older (63.4 vs. 59.7 years, p=0.04), had more arterial hypertension (AH) (91.7% vs. 84.7%, p=0.02) and dyslipidemia (58.3 vs. 38.3%, p < 0.01), and had a lower estimated baseline glomerular filtration rate (eGFR) (29.9 [21.5-42.0] vs. 39.1 [28.6-54.8] mL/min/1.73 m2, p < 0.01). Compared to PHP patients, UHS patients had a lower percentage of diabetics with glycated hemoglobin < 7.5% (46.1% vs. 61.2%, p=0.03), fewer people with potassium < 5.5 mEq/L (90.4% vs. 95.6%, p=0.04), and fewer referrals for hemodialysis with functioning arteriovenous fistula (AVF) (9.1% vs. 54.3%, p < 0.01). The percentages of people with hypertension and blood pressure < 140 × 90 mmHg were similar between the UHS and PHP groups (59.7% vs. 66.7%; p=0.17), as was the percentage of people with parathyroid hormone control (85.6% vs. 84.8%; p=0.83), dyslipidemia and LDL-cholesterol < 100 mg/dL (38.3% vs. 49.3%; p=0.13), phosphorus < 4.5 mg/dL (78.5% vs. 72.0%; p=0.16), and 25-OH-vitamin-D > 30 ng/mL (28.4% vs. 36.5%; p=0.11). The crude reduction in eGFR was greater in the UHS group than in PHP (2.3 [-0.1; 5.9] vs. 1.1 [-1.9; 4.6] mL/min/1.73 m2; p < 0.01). In the multivariate linear mixed-effects model, UHS patients also showed faster CKD progression over time than PHS ones (group effect, p < 0.01; time effect, p < 0.01; interaction, p < 0.01). Conclusions: Quality of care for patients with CKD can be improved through both services, and multidisciplinary care may have a positive impact on the control of comorbidities, the progression of CKD, and the planning of the initiation of hemodialysis.

The effect of brief educational intervention on level of awareness about chronic kidney disease among type-2 diabetes mellitus patients in Prince Sultan Military Hospital, Taif

Purpose

Lack of awareness about chronic kidney disease is prevalent and disrupts glycaemic control. In Saudi Arabia many authors highlighted the problem and called for educational interventions to be designed. Our study is the first to address this issue in Saudi Arabia and evaluate a brief educator-led educational intervention in terms of boosting awareness about and knowledge of chronic kidney disease among type two diabetes patients.

Method

This was an educational interventional investigation of patients with type two attending diabetes clinic in Taif, Saudi Arabia. The effect of a brief educational intervention focused on awareness about chronic kidney disease was assessed using chronic kidney disease knowledge scale before and after the intervention.

Results

We included (n = 100) type two diabetes patients. We estimated good reliability and internal consistency for the knowledge score (Cronbach's alpha was 0.79). Following the educational session, awareness about chronic kidney disease rose from 77 to 100% and knowledge score increased form 7.6 points at baseline to a 15.2 points; paired t value = 15.984, p < 0.00001). Improvement in awareness of chronic kidney disease was associated with being in employment, female sex, and shorter diabetes duration.

Conclusion

Brief educational intervention among patients with type two diabetes in Saudi Arabia leads to substantial improvement in awareness of and knowledge about chronic kidney disease. All items related to knowledge about chronic kidney disease improved substantially following educational intervention. It is recommended that all patients attending diabetes clinics receive focused education about chronic kidney disease.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01366-3.

Change in Liver Fibrosis Associates with Progress of Diabetic Nephropathy in Patients with Nonalcoholic Fatty Liver Disease

Diabetic nephropathy (DN) is a major complication of diabetes. Nonalcoholic fatty liver disease (NAFLD) is common in diabetes, and liver fibrosis is a prognostic risk factor for NAFLD. The interaction between DN and liver fibrosis in NAFLD remains unclear. In 189 patients with DN and NAFLD who received an education course about diabetic nephropathy, liver fibrosis was evaluated using the fibrosis-4 (FIB-4) index. The association between the outcome of DN and changes in liver fibrosis was examined. The FIB-4 index was maintained at the baseline level in patients with improved DN, while it was increased in other patients. The ΔFIB-4 index was positively correlated with changes in albuminuria and proteinuria (ρ = 0.22, p = 0.004). In a multivariate analysis, changes in albuminuria and proteinuria were associated with the ΔFIB-4 index (p = 0.002). Patients with a progressive FIB-4 index category from baseline to 5 years showed a lower event-free survival rate after 5 years than patients with an improved FIB-4 index category (p = 0.037). The outcome of DN is associated with changes in liver fibrosis in patients with diabetes, NAFLD and DN. Developing a preventive and therapeutic approach for these conditions is required.

Nursing support in the decision-making process regarding the choice of renal replacement therapy: A scoping review

Context

Chronic kidney disease affects 7 to 10 percent of the French population. Entering the end stage of the disease requires a choice to be made between several options. The aim is to document the nursing practices used to support these patients in choosing their renal replacement therapy and to determine the elements that promote decision-making.

Method

This is a scoping review based on the methodology of Peters et al. of JBI.

Results

The nursing practices identified focus on empowerment, by intervening in: involvement, providing information, clarifying preferences, supporting deliberation, and assessing needs before, during, and after the decision-making process. The key factors identified are: an equal and trusting relationship, the personalization of the process, and emotional support, all provided by trained professionals.

Discussion

Several concepts shed light on decision support in a complementary and surprisingly paradoxical way: grief, adaptation, empowerment, and uncertainty.

Conclusion

This review shows nursing practices centered on helping the patient to take control of their life decisions. This experience causes a serious upheaval in patients’ lives, hence the importance of providing them with support in managing their emotions.

Effects of one-hour discussion on the choice of dialysis modality at the outpatient clinic: A retrospective cohort study using propensity score matching

BACKGROUND

The aim of present study was to evaluate the effects of one-hour discussion on the choice of dialysis modality at the outpatient clinic.

METHODS

Charts of consecutive patients who had started maintenance dialysis from May 2013 to April 2021 were retrospectively reviewed. Characteristics at the start of dialysis were compared between patients participated and not participated in the discussion.

RESULTS

Of the 620 incident dialysis patients, 128 patients had participated in the discussion. After propensity score matching (1:1), 127 patients who participated in the discussion tended to have fewer urgent hospitalizations (13.4% vs. 21.3%, p = 0.068). In addition, more patients who initiated peritoneal dialysis (PD) (30.7% vs. 9.4%, p < 0.001). On multivariate analysis, participation in the discussion (OR 4.81, 95% CI 2.807-8.24; p < 0.001) was related to PD initiation.

CONCLUSION

One-hour discussion on the choice of dialysis modality may increase PD initiations and decrease the number of urgent hospitalizations.

Outpatient clinic specific for end-stage renal disease improves patient survival rate after initiating dialysis

The importance of a shared decision-making (SDM) approach is widely recognized worldwide. In Japan, hospital accreditation involves the promotion of SDM for patients with end-stage renal disease (ESRD) when considering renal replacement therapy (RRT). This study aimed to clarify the effectiveness and long-term medical benefits of SDM in RRT. Patients with ESRD who underwent dialysis therapy were retrospectively divided into those who visited outpatient clinics specific for ESRD (ESRD clinic) supporting RRT selection with an SDM approach (visited group) and those who did not visit the ESRD clinic (non-visited group). Data of 250 patients (129 in the non-visited group and 121 in the visited group) were analyzed. Mortality was significantly higher in the non-visited group than in the visited group. Not seeing an ESRD specialist was associated with emergent initiation of dialysis and subsequent 1 year mortality. The number of patients who chose peritoneal dialysis as a modality of RRT was significantly larger in the visited group. These findings demonstrate the association between the ESRD clinic, 1 year survival in patients with ESRD after initiating dialysis, and the different RRT modalities. This specific approach in the ESRD clinic may improve the management of patients with ESRD.

Long-term effectiveness of a primary care practice facilitation program for chronic kidney disease management: an extended follow-up of a cluster-randomized FROM-J study

BACKGROUND

Practice facilitation program by multidisciplinary care for primary care physicians (PCPs) is expected to improve chronic kidney disease (CKD) outcomes, but there is no clear evidence of its long-term effectiveness. We have previously performed a cluster-randomized controlled trial for 3.5 years (the Frontier of Renal Outcome Modifications in Japan (FROM-J) study) with two arms-group A without the program and group B with the program. We aimed to assess the long-term effectiveness of the practice facilitation program on CKD outcomes via an extended 10-year follow-up of the FROM-J study.

METHODS

We enrolled patients who were in the FROM-J study. The primary composite endpoint comprised cardiovascular disease (CVD), renal replacement therapy initiation and a 50% decrease in the estimated glomerular filtration rate (eGFR). The secondary endpoints were survival rate, eGFR decline rate and collaboration rate between PCPs and nephrologists.

RESULTS

The occurrence of the primary composite endpoint tended to be lower in group B (group A: 27.1% versus group B: 22.1%, P = 0.051). Furthermore, CVD incidence was remarkably lower in group B (group A: 10.5% versus group B: 6.4%, P = 0.001). Although both mortality and the rate of eGFR decline were identical between both groups, the eGFR decline rate was significantly better in group B than in group A only in patients with stage G3a at enrollment (group A: 2.35 ± 3.87 mL/min/1.73 m2/year versus group B: 1.68 ± 2.98 mL/min/1.73 m2/year, P = 0.02). The collaboration rate was higher in group B.

CONCLUSIONS

The CKD practice facilitation program for PCPs reliably decreases CVD events and may reduce the progression of cases to end-stage kidney disease.

"You need a team": perspectives on interdisciplinary symptom management using patient-reported outcome measures in hemodialysis care-a qualitative study

BACKGROUND

Patient-reported outcome measures (PROMs) are standardized instruments used for assessing patients' perspectives on their health status at a point in time, including their health-related quality of life, symptoms, functionality, and physical, mental, and social wellbeing. For people with kidney failure receiving hemodialysis, addressing high symptom burden and complexity relies on care team members integrating their expertise to achieve common management goals. In the context of a program-wide initiative integrating PROMs into routine hemodialysis care, we aimed to explore patients' and clinicians' perspectives on the role of PROMs in supporting interdisciplinary symptom management.

METHODS

We employed a qualitative descriptive approach using semi-structured interviews and observations. Eligible participants included adult patients receiving intermittent, outpatient hemodialysis for > 3 months, their informal caregivers, and hemodialysis clinicians (i.e., nurses, nephrologists, and allied health professionals) in Southern Alberta, Canada. Guided by thematic analysis, team members coded transcripts in duplicate and developed themes iteratively through review, refinement, and discussion.

RESULTS

Thirty-three clinicians (22 nurses, 6 nephrologists, 5 allied health professionals), 20 patients, and one caregiver participated in this study. Clinicians described using PROMs to coordinate care across provider types using the resources available in their units, whereas patients tended to focus on the perceived impact of this concerted care on symptom trajectory and care experience. We identified 3 overarching themes with subthemes related to the role of PROMs in interdisciplinary symptom management in this setting: (1) Integrating care for interrelated symptoms ("You need a team", conducive setting, role clarity and collaboration); (2) Streamlining information sharing and access (symptom data repository, common language for coordinated care); (3) Reshaping expectations (expectations for follow-up, managing symptom persistence).

CONCLUSIONS

We found that use of PROMs in routine hemodialysis care highlighted symptom interrelatedness and complexity and helped to streamline involvement of the interdisciplinary care team. Issues such as role flexibility and resource constraints may influence sustainability of routine PROM use in the outpatient hemodialysis setting.

Shared decision-making in advanced kidney disease: a scoping review

OBJECTIVES

To provide a comprehensive overview of interventions that support shared decision-making (SDM) for treatment modality decisions in advanced kidney disease (AKD). To provide summarised information on their content, use and reported results. To provide an overview of interventions currently under development or investigation.

DESIGN

The JBI methodology for scoping reviews was followed. This review conforms to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist.

DATA SOURCES

MEDLINE, Embase, Web of Science, Cochrane Library, Emcare, PsycINFO, PROSPERO and Academic Search Premier for peer-reviewed literature. Other online databases (eg, clinicaltrials.gov, OpenGrey) for grey literature.

ELIGIBILITY FOR INCLUSION

Records in English with a study population of patients >18 years of age with an estimated glomerular filtration rate <30 mL/min/1.73 m2. Records had to be on the subject of SDM, or explicitly mention that the intervention reported on could be used to support SDM for treatment modality decisions in AKD.

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently screened and selected records for data extraction. Interventions were categorised as prognostic tools (PTs), educational programmes (EPs), patient decision aids (PtDAs) or multicomponent initiatives (MIs). Interventions were subsequently categorised based on the decisions they were developed to support.

RESULTS

One hundred forty-five interventions were identified in a total of 158 included records: 52 PTs, 51 EPs, 29 PtDAs and 13 MIs. Sixteen (n=16, 11%) were novel interventions currently under investigation. Forty-six (n=46, 35.7%) were reported to have been implemented in clinical practice. Sixty-seven (n=67, 51.9%) were evaluated for their effects on outcomes in the intended users.

CONCLUSION

There is no conclusive evidence on which intervention is the most efficacious in supporting SDM for treatment modality decisions in AKD. There is a lot of variation in selected outcomes, and the body of evidence is largely based on observational research. In addition, the effects of these interventions on SDM are under-reported.

Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.

Systematic Review and Meta-Analysis Program Based on Effectiveness of a Multidisciplinary Model of Care for Patients with Chronic Kidney Disease

The effectiveness of the multidisciplinary nursing model in the nursing of chronic kidney disease (CKD) by using meta-analysis is explored. Relevant literatures that are in line with the multidisciplinary nursing model for CKD intervention are searched and screened from domestic and foreign literature databases such as Wanfang Medical Center, CNKNET, VIP, and PubMed, and Meta-analysis is conducted with RevMan 5.2 software. A total of 6 literatures are included, and the publication bias of the included literatures is low. Meta-analysis shows that the multidisciplinary group had a better Hb compliance rate, Hb level, Scr, eGFR, SBP, and DBP than the traditional group. The experimental results show that multidisciplinary nursing intervention can improve the nursing effect of patients with CKD and help to improve Hb, Scr, blood pressure, and glomerular filtration function of patients.

The impact of multidisciplinary pre-dialysis care on the outcomes of incident peritoneal dialysis patients

BACKGROUND

This study aims to evaluate the impact of multidisciplinary pre-dialysis care (MDPC) on the risks of peritonitis, technique failure and mortality in peritoneal dialysis (PD) patients.

METHODS

Incident end-stage kidney disease patients who received peritoneal dialysis (PD) for more than 90 days were recruited in this study from 1 January 1, 2007 to December 31, 2018. Patients were classified into two groups, the MDPC group and the control group, that received the usual care by nephrologists. Risks of the first episode of peritonitis, technique failure and mortality were compared between the two groups.

RESULTS

There were 126 patients under the usual care and 546 patients under the MDPC. Patients in the MDPC group initiated dialysis earlier than those in the non-MDPC group. There was no significant difference between these two groups in time to the first episode of peritonitis. Compared to the non-MDPC group, the MDPC group was at similar risks of technique failure (adjusted HR = 0.85, 95% CI = 0.64-1.15) and mortality (adjusted HR = 0.66, 95% CI = 0.42-1.02). Among patients with diabetes, the risk of mortality was significantly reduced in the MDPC group with an adjusted HR of 0.45 (95% CI = 0.25-0.80).

CONCLUSIONS

There was no significant difference in time to develop the first episode of peritonitis, and risks of technique failure and mortality between these two groups. Diabetic PD patients under MDPC had a lower risk of mortality than those under the usual care.