Choice of the Dialysis Modality: Practical Considerations

Interactive Computer-Adaptive Chronic Kidney Disease (I-C-CKD) Education for Hospitalized African American Patients: Protocol for a Randomized Controlled Trial

BACKGROUND

End-stage kidney disease (ESKD) or kidney failure is a condition where the kidneys lose the ability to function. African American individuals are 4 times as likely to develop ESKD compared to White American individuals. In addition, African American patients are less likely to have an optimal dialysis start and to choose renal replacement therapy modalities that align with their goals and values. Our prior work shows that culturally tailored, in-person education improves patient outcomes. This is the foundation for our innovative intervention using an African American virtual patient educator as an option for hospitalized patients with chronic kidney disease (CKD).

OBJECTIVE

The Interactive Computer-Adaptive Chronic Kidney Disease (I-C-CKD) study will determine whether the computerized adaptive education and usual hospital care impact the health literacy of African American patients with kidney disease. It will also assess how patients' lifestyle and commitment to health goals are impacted by the method of health literacy education.

METHODS

We will screen, recruit, and enroll hospitalized patients who self-identify as African American and have advanced CKD based on their estimated glomerular filtration rate. Eligible patients who verbally consented will be randomly assigned into either the computerized adaptive education intervention group or the control group (usual hospital care). Patients in the intervention group will receive a culturally tailored, adaptive education module. To analyze pretest, posttest, and follow-up survey results on patient CKD knowledge, ESKD treatment options, and health goals, we will use a paired, 2-tailed t test with a Bonferroni adjustment for multiple comparisons.

RESULTS

Recruitment for the I-C-CKD study began on May 2, 2023. We are currently recruiting and have enrolled 96 patients who completed both pretest and posttest surveys as of December 2024. This includes 50 patients in the control group and 46 patients in the intervention group. Data analysis has not occurred.

CONCLUSIONS

African American individuals often receive less patient education about self-care and treatment options for CKD. We hope this study provides a solution to increase hospitalized African American patients' knowledge of CKD and motivation for CKD self-care through computerized adaptive education, reduce disparities, and improve patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06364358; https://clinicaltrials.gov/study/NCT06364358.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/66846.

Chrononutrition in Chronic Kidney Disease

Chrononutrition, the study of the interaction between biological rhythms and nutrition, has emerged as a promising field for addressing metabolic health. However, its role in chronic kidney disease (CKD) remains underexplored. CKD patients often experience circadian disruptions due to renal, metabolic, treatment-related, and lifestyle factors, which may influence their nutritional status and clinical outcomes. Objective: to synthesize and analyze the existing evidence on chrononutrition in CKD patients, identify knowledge gaps, and propose directions for future research across different stages of CKD. Initially, this review contextualizes circadian physiology, alignment, and chronodisruption to explore such factors in CKD patients, focusing on chrononutrition variables already studied in the general population. We discuss how dietary timing and habit adjustments could influence CKD clinical outcomes, offering insights into circadian impacts on disease management. This new approach could optimize patient care, encouraging further research, particularly in the development of personalized strategies for different stages of the disease.

Patient screening and assessment for home dialysis therapies: A scoping review

BACKGROUND

Home dialysis therapies have limited uptake in most regions despite recognized benefits such as increasing patients' independence, and several domains of quality of life with cost savings in some systems.

OBJECTIVE

To perform a scoping review of published literature to identify tools and guides used in systematically screening and assessing patient suitability for home dialysis. A secondary objective was to explore barriers and enablers associated with the home dialysis assessment process. It is important to identify gaps in current research to pose pertinent questions for future work in the field.

DESIGN

Online databases Embase, Medline (Ovid), and CINAHL were used to identify articles published between January 2007 to May 2023. A total of 23 peer-reviewed primary and secondary studies that investigated screening or selection for patients > 18 years old with kidney failure for home dialysis met the study inclusion criteria.

RESULTS

The studies consisted of secondary studies (n = 10), observational studies (n = 8), and survey-based studies (n = 5). The major themes identified that influence patient screening and assessment for home dialysis candidacy included: screening tools and guidelines (n = 8), relative contraindications (n = 4), patient or program education (n = 9), and socioeconomic factors (n = 2).

LIMITATIONS

Consistent with the scoping review methodology, the methodological quality of included studies was not assessed. The possible omission of evidence in languages other than English is a limitation.

CONCLUSION

This scoping review identified tools and factors that potentially guide the assessment process for home dialysis candidacy. Patient screening and assessment for home dialysis requires a comprehensive evaluation of clinical, psychosocial, and logistical factors. Further research is required to validate and refine existing tools to establish standardized patient screening criteria and evaluation processes. Up-to-date training and education for healthcare providers and patients are needed to improve the utilization of home dialysis and ensure optimal outcomes.

Accounting for the Structure-Property Relationship of Hollow-Fiber Membranes in Modeling Hemodialyzer Clearance

The relevance of the hemodialysis procedure is increasing worldwide due to the growing number of patients suffering from chronic kidney disease. Taking into account the structure of dialysis polymer membranes is an important aspect in their development to achieve the required performance of hemodialyzers. We propose a new mathematical model of mass transfer that allows hollow-fiber membrane structural parameters to be taken into account in simulating the clearance (CL) of hemodialyzers in a way that does not require difficult to achieve close approximation to the exact geometry of the membrane porous structure. The model was verified by a comparison of calculations with experimental data on CL obtained using a lab-made dialyzer as well as commercially available ones. The simulations by the model show the non-trivial behavior of the dialyzer clearance as a function of membrane porosity (fp) and the arrangement of pores (α). The analysis of this behavior allows one to consider two strategies for increasing the CL of the dialyzer by optimizing the polymer membrane structure: (1) creating a membrane with a well-structured pore system (where α → 1) since doubling α at a high enough fp can lead to an almost tenfold increase in CL; (2) increasing the porosity of the membrane characterized by a random arrangement of pores (α → 0), where, at a relatively low α, a sharp increase in CL is observed with a small increase in fp over a certain threshold value.

The Socioeconomic Impact of Transport Costs for Adult Patients Requiring Haemodialysis: A Mixed Methods Study

BACKGROUND/OBJECTIVES

Patients requiring haemodialysis often perceive the cost of their travels to the dialysis centres as a significant burden. The study aimed to collect a first Swiss national data set on transport costs and assess their impact on patients and their relatives.

METHODS

In addition to interviews with patients, a quantitative survey was developed and distributed online using a voluntary sampling strategy. Data were analysed by means of descriptive statistics. A Sounding Board of patients, relatives, and healthcare professionals accompanied all steps of the project.

RESULTS

A total of 6 dialysis patients were interviewed; 437 respondents of the national survey met the inclusion criteria. Patients travel a median distance of 7.5 km to their dialysis centres. For 78% of them, the journey takes up to 30 min, and nearly half use their private car as their main mode of transport. The median annual transport costs are CHF 2925 (mean = CHF 5041). Approximately half of the patients perceive transport costs as a burden or limitation, yet only about 30% receive financial support, for which there is no standard process. Patients requiring financial support reported difficulties navigating the system.

CONCLUSIONS

This study highlighted that many dialysis patients are burdened by transport costs and receive limited financial support and counselling services. Implementation of a standardised process for financial support should be explored.

Risk factors and outcomes in patients who switched from peritoneal dialysis to physician-oriented or patient-oriented kidney replacement therapy

BACKGROUND

We aimed to compare the cardiovascular events and mortality in patients who underwent either physician-oriented or patient-oriented kidney replacement therapy (KRT) conversion due to discontinuation of peritoneal dialysis (PD).

METHODS

Patients with end-stage kidney disease who were receiving PD and required a switch to an alternative KRT were included. They were divided into physician-oriented group or patient-oriented group based on the decision-making process. Logistic regression analysis was used to explore the influencing factors related to KRT conversion in PD patients. The association of physician-oriented or patient-oriented KRT conversion with outcomes after the conversion was assessed by using Cox proportional hazards models.

RESULTS

A total of 257 PD patients were included in the study. The median age at catheterization was 35 years. 69.6% of the participants were male. The median duration of PD was 20 months. 162 participants had patient-oriented KRT conversion, while 95 had physician-oriented KRT conversion. Younger patients, those with higher education levels, higher income, and no diabetes were more likely to have patient-oriented KRT conversion. Over a median follow-up of 39 months, 40 patients experienced cardiovascular events and 16 patients died. Physician-oriented KRT conversion increased nearly 3.8-fold and 4.0-fold risk of cardiovascular events and death, respectively. After adjusting for confounders, physician-oriented KRT conversion remained about a 3-fold risk of cardiovascular events.

CONCLUSION

Compared to patient-oriented KRT conversion, PD patients who underwent physician-oriented conversion had higher risks of cardiovascular events and all-cause mortality. Factors included age at catheterization, education level, annual household income, and history of diabetes mellitus.

Assessing global and regional public interest in home dialysis modalities from 2004 to 2024

Background and objectives

Home dialysis (peritoneal dialysis and home hemodialysis) is an important renal replacement therapy modality option for patients with end-stage kidney disease. As the Internet has become a primary source for healthcare information, this study aimed to analyze the global and regional interests in home dialysis using Google Trends™ data from January 2004 to March 2024.

Design setting participants and measurements

A comprehensive analysis was conducted using Google Trends™ with the search terms "Peritoneal Dialysis" and "Home Hemodialysis." This study extracted worldwide trends and detailed regional interests within the United States. Interest levels were quantitatively assessed based on Google Trends™ indices, providing insights into temporal patterns and geographical distributions of public interest.

Results

The study found a fluctuating pattern of global interest in Peritoneal Dialysis, with peak interest in March 2022 and lowest interest in December 2008. The most recent data from March 2024 showed significant interest level of 94, indicating a new upward trend. Mexico exhibited the highest relative interest in Peritoneal Dialysis. Within the United States, Tennessee demonstrated the highest interest. For Home Hemodialysis, the peak interest was in July 2004. The most recent data from March 2024 showed a modest increase in interest. The United States led in highest relative interest for Home Hemodialysis, followed by Australia, Canada, and the United Arab Emirates. Within the United States, Mississippi demonstrated the highest interest.

Conclusions

This study offers crucial insights into the global and regional landscape of interest in home dialysis modalities over time, highlighting the significance of leveraging online platforms to increase public awareness, education, and engagement home dialysis modalities. By understanding the temporal and geographical patterns of interest, healthcare providers, policymakers, and patient advocacy groups can develop targeted strategies to better promote the benefits of home dialysis, address knowledge gaps, and improve access to these life-sustaining treatments.

Progress of nations in the organisation of, and structures for, kidney care delivery between 2019 and 2023: cross sectional survey in 148 countries

OBJECTIVE

To assess changes in key measures of kidney care using data reported in 2019 and 2023.

DESIGN

Cross sectional survey in 148 countries.

SETTING

Surveys from International Society of Nephrology Global Kidney Health Atlas between 2019 and 2023 that included participants from countries in Africa (n=36), Eastern and Central Europe (n=16), Latin America (n=18), the Middle East (n=11), Newly Independent States and Russia (n=10), North America and the Caribbean (n=8), North and East Asia (n=6), Oceania and South East Asia (n=15), South Asia (n=7), and Western Europe (n=21).

PARTICIPANTS

Countries that participated in both surveys (2019 and 2023).

MAIN OUTCOME MEASURES

Comparison of 2019 and 2023 data for availability of kidney replacement treatment services, access, health financing, workforce, registries, and policies for kidney care. Data for countries that participated in both surveys (2019 and 2023) were included in our analysis. Country data were aggregated by International Society of Nephrology regions and World Bank income levels. Proportionate changes in the status of these measures across both periods were reported.

RESULTS

Data for 148 countries that participated in both surveys were available for analysis. The proportions of countries that provided public funding (free at point of delivery) increased from 27% in 2019 to 28% in 2023 for haemodialysis, 23% to 28% for peritoneal dialysis, and 31% to 36% for kidney transplantation services. Centres for these treatments increased from 4.4 per million population (pmp) to 4.8 pmp (P<0.001) for haemodialysis, 1.4 pmp to 1.6 pmp for peritoneal dialysis, and 0.43 pmp to 0.46 pmp for kidney transplantation services. Overall, access to haemodialysis and peritoneal dialysis improved, however, access to kidney transplantation decreased from 30 pmp to 29 pmp. The global median prevalence of nephrologists increased from 9.5 pmp to 12.4 pmp (P<0.001). Changes in the availability of kidney registries and in national policies and strategies for kidney care were variable across regions and country income levels. The reporting of specific barriers to optimal kidney care by countries increased from 55% to 59% for geographical factors, 58% to 68% (P=0.043) for availability of nephrologists, and 46% to 52% for political factors.

CONCLUSIONS

Important changes in key areas of kidney care delivery were noted across both periods globally. These changes effected the availability of, and access to, kidney transplantation services. Countries and regions need to enact enabling strategies for preserving access to kidney care services, particularly kidney transplantation.

Developing a haemodialysis acuity tool (the HAT study): A qualitative study

BACKGROUND

Haemodialysis units are now managing an increasing number of patients with varying needs and levels of acuity. To maintain safety, haemodialysis patients must be placed in the most appropriate dialysis unit that has the required human and physical resources to care for them. The first step towards achieving these goals is to develop a tool specific to haemodialysis units to effectively measure patient acuity.

OBJECTIVE

To develop a haemodialysis acuity tool, utilising a focus group approach, in assessing patient's suitability for a specific dialysis location thus ensuring patient safety.

DESIGN

This is a cross-sectional qualitative study via a focus group approach.

PARTICIPANTS

Participants were nurse unit managers and team leaders of a District Renal Service.

APPROACH

Participants were interviewed to explore their views on the elements and measures identified in the research aims. Themes for interviews were informed by current literature on acuity tools for haemodialysis patients' admission to the dialysis units. Interviews were recorded and transcribed verbatim and progressively analysed using a thematic analysis approach.

RESULTS

Ten nurse unit managers/team leaders (100%) were interviewed and thematic analysis of the transcripts was conducted utilising the deductive approach. Five themes were identified which will form the main categories in the development of the tool, namely: Age/frailty; co-morbidity; physical; dialysis; and psychosocial.

CONCLUSION

This study is instrumental in the development of the haemodialysis acuity tool which can be used in allocating dialysis location specific to patient's needs and available resources. The tool can also be used in analysing patient care processes and resource requirements based on the patients' and unit's profile.