Association of increased travel distance to dialysis units with the risk of anemia in rural chronic hemodialysis elderly

Impact of variables on recovery time in patients undergoing hemodialysis: an international survey

BACKGROUND

Dialysis recovery time (DRT) refers to the period during which fatigue and weakness subside following hemodialysis treatment, allowing patients to resume their daily routines. This study aimed to identify the factors influencing DRT in hemodialysis patients in Turkey and Portugal, where the prevalence of chronic kidney disease is notably high.

METHODS

A cross-sectional observational study was conducted in a private dialysis center in Turkey and three dialysis centers in Portugal. The study included hemodialysis patients aged 18 years or older who had been undergoing four-hour hemodialysis sessions three times a week for at least six months. Participants had no communication barriers and voluntarily agreed to take part in the study. Data were collected using a semi-structured questionnaire to gather descriptive characteristics and the Hospital Anxiety and Depression Scale. Logistic regression analysis was employed to identify independent variables influencing DRT.

RESULTS

A total of 294 patients participated in the study, including 187 from Turkey and 107 from Portugal. In Turkey, increased interdialytic weight gain (P = 0.043) was associated with prolonged recovery time, while the use of high-flux dialyzers (P = 0.026) was linked to shorter recovery times. In Portugal, older age (P = 0.020) was found to extend recovery time.

CONCLUSION

Recovery time after dialysis is influenced by varying factors across different countries. Further research with larger sample sizes is needed to deepen understanding of these factors and their implications.

CLINICAL TRIAL NUMBER

NCT04667741.

Association between Residential Distance from Home to Hospital and Amputation of a Lower Extremity among Peripheral Artery Disease Patients in Japan

Lack of access to care can lead to poor outcomes for patients with peripheral artery disease (PAD). We investigated the association between residential distance from home to hospital and amputation of the lower extremity among PAD patients in the Chiba peninsula, Japan. A retrospective cohort study with an average follow-up period of 2.96 years was conducted using data from 630 PAD patients who visited two hospitals in the Chiba peninsula, Japan, between 1 April 2010 to 31 March 2020. Information on disease status, residential address, and covariates was obtained from medical records. The association between amputation of a lower extremity, including toe amputation, and residential distance was evaluated by Cox proportional hazards model. Age, gender, Fontaine class, endovascular treatment, dialysis, diabetes mellitus, hypertension, dyslipidemia, current or past smoking, and aspirin use were adjusted. The median residential distance was 18.9 km (interquartile range, IQR: 22.1). Ninety-two patients (14.6%) underwent amputation of the lower extremity during the follow-up period. The longer residential distance was significantly associated with a higher risk of lower extremity amputation (hazard ratio per IQR = 1.35, 95% confidence interval, 1.01-1.82) after adjusting for covariates. Poorer access to a hospital, assessed as a longer residential distance from home to a hospital, was associated with amputation of the lower extremity among PAD patients.

Understanding the Tradeoffs Between Travel Burden and Quality of Care for In-center Hemodialysis Patients

BACKGROUND

Renal dialysis is a lifesaving but demanding therapy, requiring 3 weekly treatments of multiple-hour durations. Though travel times and quality of care vary across facilities, the extent to which patients are willing and able to engage in weighing tradeoffs is not known. Since 2015, Medicare has summarized and reported quality data for dialysis facilities using a star rating system. We estimate choice models to assess the relative roles of travel distance and quality of care in explaining patient choice of facility.

RESEARCH DESIGN

Using national data on 2 million patient-years from 7198 dialysis facilities and 4-star rating releases, we estimated travel distance to patients' closest facilities, incremental travel distance to the next closest facility with a higher star rating, and the difference in ratings between these 2 facilities. We fit mixed effects logistic regression models predicting whether patients dialyzed at their closest facilities.

RESULTS

Median travel distance was 4 times that in rural (10.9 miles) versus urban areas (2.6 miles). Higher differences in rating [odds ratios (OR): 0.56; 95% confidence interval (CI): 0.50-0.62] and greater area deprivation (OR: 0.50; 95% CI: 0.48-0.53) were associated with lower odds of attending one's closest facility. Stratified models were also fit based on urbanicity. For rural patients, excess travel was associated with higher odds of attending the closer facility (per 10 miles; OR: 1.05; 95% CI: 1.04-1.06). Star rating differences were associated with lower odds of receiving care from the closest facility among urban (OR: 0.57; 95% CI: 0.51-0.63) and rural patients (OR: 0.18; 95% CI: 0.08-0.44).

CONCLUSIONS

Most dialysis patients have higher rated facilities located not much further than their closest facility, suggesting many patients could evaluate tradeoffs between distance and quality of care in where they receive dialysis. Our results show that such tradeoffs likely occur. Therefore, quality ratings such as the Dialysis Facility Compare (DFC) Star Rating may provide actionable information to patients and caregivers. However, we were not able to assess whether these associations reflect a causal effect of the Star Ratings on patient choice, as the Star Ratings served only as a marker of quality of care.

Factors Affecting Hemodialysis Adequacy in Cohort of Iranian Patient with End Stage Renal Disease

BACKGROUND

There are many factors that can affect dialysis adequacy; such as the type of vascular access, filter type, device used, and the dose, and rout of erythropoietin stimulation agents (ESA) used. The aim of this study was investigating factors affecting Hemodialysis adequacy in cohort of Iranian patient with end stage renal disease (ESRD).

METHODS

This is a cross-sectional study conducted on 133 Hemodialysis patients referred to two dialysis units in Sistan-Baluchistan province in the cities of Zabol and Iranshahr, Iran. We have looked at, (the effects of the type of vascular access, the filter type, the device used, and the dose, route of delivery, and the type of ESA used) on Hemodialysis adequacy. Dialysis adequacy was calculated using kt/v formula, two-part information questionnaire including demographic data which also including access type, filter type, device used for hemodialysis (HD), type of Eprex injection, route of administration, blood groups and hemoglobin response to ESA were utilized. The data was analyzed using the SPSS v16 statistical software. Descriptive statistical methods, Mann-Whitney statistical test, and multiple regressions were used when applicable.

RESULTS

The range of calculated dialysis adequacy is 0.28 to 2.39 (units of adequacy of dialysis). 76.7% of patients are being dialyzed via AVF and 23.3% of patients used central venous catheters (CVC). There was no statistical significant difference between dialysis adequacy, vascular access type, device used for HD (Fresenius and B. Braun), and the filter used for HD (p> 0.05). However, a significant difference was observed between the adequacy of dialysis and Eprex injection and patients' time of dialysis (p <0.05).

CONCLUSION

Subcutaneous ESA (Eprex) injection and dialysis shift (being dialyzed in the morning) can have positive impact on dialysis adequacy. Patients should be educated on the facts that the type of device used for HD and the vascular access used has no significant effects on dialysis adequacy.

Geographic disparities in mortality among the end stage renal disease patients: an analysis of the United States Renal Data System, 2007-08

The study was conducted to determine the association between mortality, rurality, and distance from the treatment facility of the patients with ESRD. The United States Renal Data System (USRDS) for the year 2007-08 was utilized to conduct analysis of 181,349 subjects. After adjusting for all other covariates, the odds of mortality were higher among patients in urban and isolated areas (18.1 miles or more from the dialysis facility), compared with those who were living closer (≤3.3 miles, OR 1.08, 95 % CI 1.05-1.12). Conversely, patients living in isolated rural (0-≤3.3 miles, OR 0.95, 95 % CI 0.81-0.96), small adjacent rural (8.1-≤18.1 miles, OR 0.90, 95 % CI 0.77-0.96) and Micropolitan rural quartiles (>18.1 miles, OR 0.96, 95 % CI 0.92-0.97) had lower odds of mortality than their urban counterparts. The Accountable Care Organizations must devise strategies to cater ESRD patients living in remote areas.

Geriatric syndromes are potential determinants of the medication adherence status in prevalent dialysis patients

Background. Geriatric syndromes (GS) exhibit high prevalence in patients with end-stage renal disease (ESRD) under chronic dialysis irrespective of age. We sought to determine whether GS influences medication adherence in ESRD patients.

Methods. A prospective cohort of chronic dialysis patients was assembled. The presence of GS components, including frailty/prefrailty, polypharmacy, and malnutrition, were ascertained through a validated questionnaire, electronic records and chart abstraction, and laboratory tests. The severity of medication non-adherence was defined using the eight-item Morisky Medication Adherence Scale (MMAS). Multiple logistic regression analysis was performed targeting MMAS results and incorporating relevant clinical features and GS.

Results. The prevalence of frailty/pre-frailty, polypharmacy, and hypoalbuminemia/ malnutrition among the enrolled participants was 66.7%, 94%, and 14%, respectively. The average MMAS scores in these dialysis patients were 2 ± 1.7 (range, 0–6), with only 15.7% exhibiting high medication adherence. Multiple regression analyses showed that the absence of frailty/pre-frailty (P = 0.01) were significantly associated with poorer medication adherence, while the presence of polypharmacy (P = 0.02) and lower serum albumin, a potential sign of malnutrition (P = 0.03), were associated with poor adherence in another model.

Conclusion. This study is among the very few reports addressing GS and medication adherence, especially in ESRD patients. Interventions targeting frailty, polypharmacy, and malnutrition might potentially improve the medication non-adherence and symptom control in these pill-burdened patients.

Impacts of Geographic Distance on Peritoneal Dialysis Utilization: Refining Models of Treatment Selection

OBJECTIVE

To examine the relationship between distance to dialysis provider and patient selection of dialysis modality, informed by the absolute distance from a patient's home and relative distance of alternative modalities.

DATA SOURCES

U.S. Renal Data System.

STUDY DESIGN

About 70,131 patients initiating chronic dialysis and 4,795 dialysis facilities in 2006. The primary outcome was patient utilization of peritoneal dialysis (PD). Independent variables included absolute distance between patients' home and the nearest hemodialysis (HD) facility, relative distance between patients' home and nearest PD versus nearest HD facilities, and their interaction. Logistic regression was used to model distance on PD use, controlling for patient and market characteristics.

PRINCIPAL FINDINGS

Nine percent of incident dialysis patients used PD in 2006. There was a positive, nonlinear relationship between absolute distance to HD services and PD use (p < .0001), with the magnitude of the effect increasing at greater distances. In terms of relative distance, odds of PD use increased if a PD facility was closer or the same distance as the nearest HD facility (p = .006). Interaction of distance measures to dialysis facilities was not significant.

CONCLUSIONS

Analyses of patient choice between alternative treatments should model distance to reflect all relevant dimensions of geographic access to treatment options.

Establishment of a renal supportive care program: Experience from a rural community hospital in Taiwan

Renal supportive care (RSC) denotes a care program dedicated for patients with acute, chronic renal failure, and end-stage renal disease (ESRD), aiming to offer maximal symptom relief and optimize patients' quality of life. The uncertainty of prognosis for patients with chronic kidney disease and ESRD, the sociocultural issues inherent to the Taiwanese society, and the void of structured and practical RSC pathway, contributes to the underrecognition and poor utilization of RSC. Taiwanese patients rarely receive information regarding RSC as part of a standardized care and are not commonly offered this option. In National Taiwan University Hospital Jinshan branch, we started a RSC subprogram, supported by the community-based palliative/hospice care main program. We focused on understanding the need and providing the choice of RSC to suitable candidates. A three-step and four-phase protocol was designed and implemented to identify appropriate patients and to enhance the applicability of the RSC. We harnessed family visit and home-based family meeting as a vehicle to understand the patients' preferences, to discover what ESRD patients and their family value most, and to introduce the option of RSC. In the current review, we described our pilot experience of establishing a RSC program in Taiwan, and discuss its potential advantage.

Simple self-report FRAIL scale might be more closely associated with dialysis complications than other frailty screening instruments in rural chronic dialysis patients

AIM

Despite the perceived importance of frailty, few studies focus on its impact on rural patients undergoing chronic dialysis. Comparison of different self-report questionnaires in assessing frailty among these patients has not been attempted before.

METHODS

A prospectively enrolled chronic dialysis cohort from a rural centre was recruited for analysis. Six types of self-report questionnaires were administered to these patients. Clinical and dialysis-related laboratory parameters were collected. Correlation analyses between questionnaire results and dialysis complications were performed, and variables demonstrating significant correlations were entered into multivariate regression models to determine their independent associations.

RESULTS

Six types of questionnaire (Strawbridge questionnaire, Edmonton Frail Scale, simple FRAIL scale, Groningen Frail Indicator, G8 questionnaire, and Tilburg Frail Indicator) were provided to rural patients undergoing chronic dialysis. Scores from each questionnaire showed significant association with each other, except the G8 questionnaire. Scores from the simple FRAIL scale correlated significantly with age (P = 0.02), female gender (P = 0.03), higher Liu's comorbidity index (P = 0.02), lower serum albumin (P = 0.03) and creatinine levels (P < 0.01), and higher ferritin levels (P = 0.02). The other five questionnaires did not show consistently significant relationships with important dialysis-related complications. Multivariate linear regression analysis identified an independently negative association between serum albumin and the simple FRAIL scale results (P = 0.01).

CONCLUSION

This is the first study establishing the utility of different self-report questionnaires for assessing frailty in chronic dialysis patients. The simple FRAIL scale scores might demonstrate a closer relationship with dialysis-related complications.

Frailty severity is significantly associated with electrocardiographic QRS duration in chronic dialysis patients

End-stage renal disease (ESRD) patients are at increased risk of sudden cardiac death, the risk of which is presumably related to arrhythmia. Electrocardiographic (ECG) parameters have been found to correlate with arrhythmia and predict cardiovascular outcomes in ESRD patients. Frailty is also a common feature in this population. We investigate whether the severity of dialysis frailty is associated with ECG findings, including PR interval, QRS duration, and QTc interval. Presence and severity of frailty was ascertained using six different self-report questionnaires with proven construct validity. Correlation analysis between frailty severity and ECG was made, and those with significant association entered into multiple regression analysis for confirmation. Among a cohort of chronic hemodialysis patients, we found that frailty severity, assessed by the Edmonton frailty scale, is significantly associated with QRS duration (r = − 0.3, p < 0.05). Dialysis patients with QRS longer than 120 ms had significantly lower severity of frailty than those with QRS less than 120 ms (p = 0.01 for the Edmonton frailty scale and 0.05 for simple FRAIL scale). Regression analysis showed that frailty severity, assessed by the Edmonton frailty scale and simple FRAIL scale, was significantly associated with QRS duration independent of serum electrolyte levels. In conclusion, a significant relationship exists between the severity of frailty and QRS duration in ESRD patients. This might be an under-recognized link between frailty and its adverse cardiovascular impact in these patients.