Patient-Centered Quality Measures for Dialysis Care: A Report of a Kidney Disease Outcomes Quality Initiative (KDOQI) Scientific Workshop Sponsored by the National Kidney Foundation

Incidence of major urological cancers in patients on dialysis: a systematic review and meta-analysis

BACKGROUND

Studies have demonstrated an elevated risk of urological malignancies in individuals undergoing dialysis, which consequently leads to unfavorable prognoses and diminished quality of life for patients with end-stage kidney disease. Nevertheless, the absence of standardized recommendations for cancer screening and limited utilization of conventional screening methods within the dialysis population remain prevalent issues.

METHODS

A meta-analysis was conducted on cohort studies published prior to June 2024, aiming to quantify the cancer risk among individuals undergoing dialysis. Random-effects meta-analyses were employed to combine standardized incidence rates (SIRs) along with their corresponding 95% confidence intervals, considering a p-value of less than 0.05 or an I² value exceeding 50%. Subgroup analyses, heterogeneity tests, and sensitivity analyses were performed as well.

RESULTS

A total of 10 studies, consisting of 12 cohort studies, were ultimately identified, encompassing a collective patient population of 1,362,196 individuals. Compared to the general population, the pooled SIRs for all cancers except non-melanoma skin cancer (NMSC), major urological cancers (MUCs), cancers of the kidney/renal pelvis, bladder cancers and prostate cancers were 1.40 (95% CI: 1.28-1.54), 1.76 (95% CI: 1.45-2.14), 4.73 (95% CI: 3.96-5.64), 1.89 (95% CI: 1.61-2.21) and 0.94 (95% CI: 0.79-1.11), respectively. The cancer risk was notably elevated in specific subgroups of women, younger patients (age at first dialysis, 0-34 years), during the initial year of dialysis, and among Asian patients. SIRs differed when considering different primary renal diseases. However, high heterogeneity was observed among the studies investigating cancers during dialysis, while this heterogeneity did not have a substantial impact on the pooled SIRs for overall cancer, as determined through sensitivity analysis.

CONCLUSIONS

Compared with the general population, the dialysis population had a significantly increased risk of developing urological malignancies, particularly cancers of the kidney/renal pelvis. Our findings indicate a substantial increase in risks among female, young, Asian patients, during the first year of dialysis and highlight variations in SIRs based on primary renal disease. These results suggest the potential for adopting a more personalized approach to cancer screening in chronic dialysis patients. Given the considerable heterogeneity observed, further rigorous investigations are warranted to enhance our understanding in this area.

Home dialysis: there's no place like home

PURPOSE OF REVIEW

The rapid rise in incidence and prevalence of end-stage kidney disease (ESKD) over the past 50 years was matched by a drop-off in use of home dialysis and a proliferation of in-center hemodialysis across the United States. There is renewed interest in improving access to home dialysis modalities for patients with ESKD. The aim of this review is to update kidney care providers with clinical outcome data and new guidelines that promote patient-centered choices, and to address barriers to home dialysis uptake and continued use.

RECENT FINDINGS

Recent literature, including changing practice guidelines for prescribing home dialysis and examining the goals of treatment from the patient and caregiver perspectives will be reviewed. We will examine the impact of newer care models to promote home dialysis for incident ESKD patients. Assisted home dialysis, home dialysis in a nursing home and the impact of new payment models rewarding home dialysis providers will be examined.

SUMMARY

This concise review of recent pertinent literature should give the dialysis provider confidence in advising their patients on the benefits of home dialysis, a glimpse into the future landscape for home dialysis, and hopefully transform kidney care providers into unbiased patient advocates.

Understanding Health Literacy in Fluid Management in Individuals Receiving Haemodialysis: A Directed Qualitative Content Analysis

AIMS

To describe the perspectives of individuals receiving haemodialysis regarding health literacy in fluid management.

DESIGN

A qualitative descriptive approach using directed content analysis of interviews from an explanatory mixed methods study.

METHODS

Semi-structured individual interviews were conducted from September 2020 to February 2021 with 28 individuals receiving haemodialysis who had attended a prior quantitative study. A directed qualitative content analysis approach was used to identify categories and subcategories emerging from the data.

RESULTS

Six categories of health literacy were identified: (1) active health management, (2) engagement with healthcare providers, (3) understanding and support from healthcare providers, (4) social support, (5) health information literacy and (6) navigation of the healthcare system.

CONCLUSIONS

Based on their real-life experience, individuals receiving haemodialysis have unique health literacy needs regarding fluid management. A comprehensive understanding of these unique needs is crucial in creating person-centered interventions to address inadequate fluid restriction.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Interventions to address inadequate fluid restriction should be person-centered, considering each individual's unique health literacy needs. This involves conducting a comprehensive assessment of individuals' health literacy needs, empowering individuals to actively engage in health, engaging the entire support network and facilitating health information literacy in line with individuals' preferences.

IMPACT

This study offers detailed insights into the health literacy needs related to fluid management in individuals undergoing haemodialysis. The findings could inform the development of person-centered fluid management strategies for these individuals.

REPORTING METHOD

We adhered to the Consolidated Criteria for Reporting Qualitative Research checklist.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Prospective Analysis of Arteriovenous Fistula Performance in the Context of Competing Risks

Key Points

Among 257 newly created arteriovenous fistulas, primary nonfunction occurred in 49%, and only 55% were ultimately used for dialysis. Loss of arteriovenous fistula patency was lower when competing risks were accounted for compared with conventional Kaplan–Meier analysis. We present icon-array plots that summarize our data and may be used a decision aid for patients in the future.

Background

Many patients with newly created arteriovenous fistulas (AVFs) may die before the AVF is needed for hemodialysis. However, formal competing risks (CRs) frameworks are rarely used to report AVF patency, which may lead to biased estimates. We sought to identify the proportion of newly created AVF experiencing primary nonfunction and describe long-term patency using a CR framework.

Methods

We conducted a prospective observational study in 257 adults with newly created AVF in Alberta, Canada. The primary outcome was primary nonfunction. Secondary outcomes included loss of primary patency, loss of assisted primary patency, and loss of secondary functional patency. Results were presented using icon-array plots to form the basis for future decision aids.

Results

Participants were 63.0% male, with mean age 62.3 years and median follow-up 18.5 months (range, 0.02–180 months). Of 257 participants, 50 could not be assessed for function or primary nonfunction, usually because of death. Of the remaining 207, 102 (49.3%) had primary nonfunction, and function was ultimately established for 142 (68.6%). Thus, only 142 of the 257 participants (55.3%) ultimately used the AVF for hemodialysis. High rates of CRs led to biased results from Kaplan–Meier analyses of lost patency. When accounting for CRs, loss of primary patency among AVFs with established function was 36.6%, 65.5%, and 66.2%, at 1, 3, and 5 years, respectively.

Conclusions

Only 55% of fistulas were ultimately used for hemodialysis when accounting for CRs and primary nonfunction. These results and the icon-array plots may inform discussions surrounding vascular access options for patients.

Personalized peritoneal dialysis prescription-beyond clinical or analytical values

Traditionally, dialysis adequacy has been assessed primarily by determining the clearance of a single small solute, urea. Nevertheless, it has become increasingly evident that numerous other factors play a crucial role in the overall well-being, outcomes and quality of life of dialysis patients. Consequently, in recent years, there has been a notable paradigm shift in guidelines and recommendations regarding dialysis adequacy. This shift represents a departure from a narrow focus only on the removal of specific toxins, embracing a more holistic, person-centered approach. This new perspective underscores the critical importance of improving the well-being of individuals undergoing dialysis while simultaneously minimizing the overall treatment burden. It is based on a double focus on both clinical outcomes and a comprehensive patient experience. To achieve this, a person-centered approach must be embraced when devising care strategies for each individual. This requires a close collaboration between the healthcare team and the patient, facilitating an in-depth understanding of the patient's unique goals, priorities and preferences while striving for the highest quality of care during treatment. The aim of this publication is to address the existing evidence on this all-encompassing approach to treatment care for patients undergoing peritoneal dialysis and provide a concise overview to promote a deeper understanding of this person-centered approach.