The role of remote patient monitoring in peritoneal dialysis – understanding patient perspectives

Dr Benjamin Talbot1,2, Dr Sara Farnbach3, Professor Steve Chadban4,5, Dr Shaundeep Sen2,6, Professor Martin Gallagher1,2,6, Professor John Knight1

1The George Institute for Global Health, University of New South Wales, Sydney, Australia, 2Concord Clinical School, University of Sydney, Sydney, Australia, 3National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia, 4Charles Perkins Centre, University of Sydney, Sydney, Australia, 5Royal Prince Alfred Hospital, Sydney, Australia, 6Concord Repatriation General Hospital, Sydney, Australia

Introduction

Remote patient monitoring (RPM) has potential to assist with managing patients treated with peritoneal dialysis (PD), offering possible financial and environmental savings in addition to improved clinical oversight and patient support. Despite this, few studies have considered patients’ perspectives regarding RPM in PD management. We aimed to identify current practices of data recording/patient monitoring in PD and to better understand consumer opinion regarding the role of RPM.

Method

Patients, caregivers and healthcare providers from an urban PD facility in Australia were purposefully selected and invited to complete qualitative semi-structured interviews. Interviews were recorded, transcribed and inductively coded using grounded theory.

Results

Nine PD patients and 5 healthcare professionals (2 physicians, 3 PD nurses) were interviewed. Median patient age was 69 years (IQR 64-73), median duration of PD therapy was 30 months (IQR 6-42) and 2 patients were using RPM at the time of interview.  Preliminary analysis has identified major themes regarding current data monitoring practices, including: 1. influence of dialysis unit preference on patients’ data recording practices and 2. differing patient practices regarding abnormal data. Major themes developed regarding the role of RPM include: 1. impact of RPM to clinical care, 2. change in patient-dialysis unit relationships, 3. data sharing/protection, and 4. perceived barriers to data recording.

Conclusion

RPM may offer a useful adjunct to the care of patients treated with PD, however, some patients and healthcare providers have concerns about potential barriers and data security. Participants also identified potential for RPM use to alter the patient-dialysis unit relationship.


Biography:

Benjamin Talbot is a renal advanced trainee from the UK currently completing a PhD at the George Institute for Global Health, Sydney, Australia

Novel pneumatic compression device may dilate veins for home hemodialysis

Dr Tej Singh1

1Fist Assist Devices, LLC, Los Altos, United States

Introduction: Home hemodialysis (HHD) is the future of cost saving global dialysis. Radiocephalic fistulas (RCF) are the preferred type of arteriovenous fistula (AVF) over  brachiocephalic fistulas (BCF). Intermittent compression of upper arm veins may aid in forearm vein dilation.

Methods: This was an IRB approved study. After AVF creation, a novel, intermittent pneumatic compression device [Fist Assist® (FA)] was applied 15 cm proximal to AVF to apply cyclic compression of 60 mm Hg for six hours daily for 30 days. Among the patients who completed one month follow up, forty-one (n=41) AVF patients were in the study arm to test vein dilation with FA. Of these patients, twenty-four (n=24) had BCFs, while seventeen (n=17) had RCFs. Controls (n=16) used a sham device. Vein size was measured and recorded at baseline and after 30 days by duplex measurement. Clinical results (percentage increase) were recorded and tested for significance.

Results: No patients experienced adverse effects. After one month, the mean percentage increase in vein diameter in the FA treatment group with RCFs was significantly larger than those with BCFs at proximal locations of 5 cm, 10 cm, and 15 cm from the anastomosis (p=0.001, 0.000, and 0.006, respectively) compared to the control group.

Conclusions: Early application of an intermittent pneumatic compression may be more effective at helping RCFs mature for HHD. Improved RCF maturation is important for vascular access care and has been an important goal. Successful RCF maturation may help preserve upper arm veins for future use in HHD.


Biography:

Tej Singh, MD, MBA, LEAD is a Silicon Valley Vascular and Endovascular Surgeon. He is a graduate of the University of Chicago and Stanford University Business Programs. He has a busy vascular access surgical practice and now has patented technology for vein dilation. He is the CEO and Founder of Fist Assist Devices, LLC for vein dilation devices.

Peritoneal Dialysis Retraining program: Empowering patients to reduce individual peritonitis risk factors

Mrs Deanna Shephard1

1Logan Hospital, Meadowbrrok, Australia

Introduction: Peritonitis is the leading cause of morbidity and mortality in peritoneal dialysis (PD) patients and is a major cause of technique failure and patient admissions. International guidelines recommend routine retraining of patients on PD to reduce the risk of peritonitis. This poster will describe a quality initiative, aimed at improving the process of retraining and empowering patients with the knowledge to reduce their modifiable risk factors for peritonitis, within a metropolitan PD unit.

Method:

A template was designed after a literature review, analysis of adult learning principles and collaboration with PDU staff, creating a structured format to utilise for retraining in the patient’s home environment. Home visits were prioritised according to international guidelines which suggest three months post initial train and minimum of annually thereafter, post peritonitis, catheter infection, hospitalisation, decline in dexterity, cognition or vision.

Results:

Currently 31 of 62 patients have been retrained. Preliminary data comparing three-months post intervention to the same period in the previous year, indicates a reduction in peritonitis rate from 0.53 to 0.26 per patient year.  Total length of hospital stay decreased from 101.7 to 70.7 days and hospital admissions from 15 to 11.7.

Conclusion:

Although there are many variables that influence this data, these results indicate improvements that may be amplified once all patients are retrained. Furthermore, data collected from patient retraining has provided insight into specific education topics, that we as clinicians can improve on to assist patients to retain the vital information necessary to safely perform a home-based therapy.


Biography:

Commencing nursing in haematology and bone marrow transplantation for 18 months, I progressed to working in various areas of nursing before settling into renal nursing, where I have spent the past 13 years. I enjoy the challenge of empowering patients to take charge of their health outcomes, by partnering with them on their health care journey.

Hospital haemodialysis patients’ and nurses’ perceived barriers to home-based therapy

Dr Adam Mullan1,2, Dr Walaa Saweirs1,2, Lisa Harvey-Jack1, Jill Rengatch1, Nikki Ferris1

1Northland District Health Board, , New Zealand, 2University of Auckland, Auckland, New Zealand

Home based dialysis has been shown to improve quality of life.  Over the last ten years there has been a decline in the proportion of individuals embarking upon home based dialysis in Northland (New Zealand), such that only 28.6% were undertaking a home therapy as of August 2019.  The reasons for this decline are multi-factorial, and include an ageing and increasingly co-morbid population (Diabetes mellitus is the cause ESKD in 57.5%), resource constraints and patient specific factors.

In order to better understand the impact of these latter factors we undertook a survey of all prevalent hospital haemodialysis patients.  The aim of the survey was to assess the perceived barriers to home based therapy from the perspectives of patients currently on hospital haemodialysis and, independently, their primary haemodialysis nurse.  The survey was delivered in an independent and non-confrontational manner either utilising an electronic survey tool (Survey Monkey®) or via a paper equivalent depending upon patient choice.  The plan is to subsequently survey those on a home based therapy as well as those currently being managed by our Chronic Kidney Disease team at the time of their home visit or family meeting.

We present the results of the initial survey of those on hospital based haemodialysis.  This is part of our team’s aim to better understand the real barriers to home therapy faced by our specific population with a view to utilising consumer co-design methodology in order to increase the uptake of home-based therapy.


Biography:

I graduated from the University of Edinburgh in 1994 with honours having also undertaken a one year intercalated degree in immunopathology.  I went on to complete a basic science PhD (MRC Clinical Research Fellowship) in 2005 at the University of Edinburgh.  This was primarily at a molecular level using recombinant DNA technology together with protein purification techniques to produce MHC class II-peptide tetramers using Goodpasture antigen peptide fragments.  The intention was to identify auto-antigen specific CD4 positive T cells in Goodpasture’s Disease.  I successfully developed the basic MHC class II-peptide monomers with a view to forming the tetrameric constructs.

Having completed my clinical nephrology and general medical training in Scotland, I came to New Zealand in 2007.  I have been the PD Clinical lead for the unit from an early stage, and have been the Clinical Director of Nephrology services in Northland since 2017.  I am one of the founding faculty members of the ANZ PD Academy, and have been lecturing at the annual clinical meeting since its inception in 2011.  I have been Chair of the New Zealand PD Registry since January 2017.

I was an investigator in the CARI PD implementation project to assess anti-microbial prophylaxis. I was the local clinical lead for a Ministry of Health Diabetes and CKD management project which reported in 2013 and formed the foundation of the New Zealand national Chronic Kidney Disease in Primary Care pathway.

I was a Principle Investigator for the AKTN CKD-FIX. I am currently an investigator in a national study “The genetic cause of End Stage Renal Disease in Aoteoroa, New Zealand” as well as TEACH-PD.

Peritonitis risk factors: A single unit review of peritonitis patient specific characteristics

Mrs Robyn Rogers1, Associate Professor  Ken-Soon Tan1

1Logan Renal Services, Meadowbrook, Australia

Introduction

Peritonitis is a known major cause of peritoneal dialysis (PD) technique failure, as well as a leading cause of hospitalisation. There are many reported risk factors, modifiable and non-modifiable. We reviewed our PD unit’s non-peritonitis patient group with our peritonitis patient group, evaluating demographic and physical differences and therefore identify patients at greater risk for peritonitis episodes.

Method

All peritonitis episodes were reviewed from 1st January 2016 to 30th June 2019. During this study period, 47 of 134 incident patients, had a total of 72 episodes of peritonitis. Patient demographics and physical factors were studied, including ethnicity, dialysis type, age, gender, diabetic status, BMI, serum albumin and potassium. This data was then compared with the same factors in our non-peritonitis PD population.

Results

Initial review of data collected from our patient population, indicated that the peritonitis group of patients were predominately male, diabetic and on APD. Caucasian, Pacific Islander/Maori/ Indian patients had more episodes of peritonitis compared to our Asian and Aboriginal/Torres Strait Islander patients.

However, further regression analysis when calculated, did not show statistically significant differences in these factors, probably due to limited study numbers.

Conclusion

Interventions can be made to improve modifiable risk factors; however, the non-modifiable risk factors present more of a challenge. Awareness of other demographical non-modifiable risk factors allows early identification of patients that may be at a greater risk for peritonitis.


Biography:

I have been working as a Clinical Nurse Consultant at the Logan Hospital Peritoneal Dialysis Unit for the last 10 years, but have been worked across various areas of Nephrology including CKD, Pre-dialysis and Haemodialysis for 30 years.  I enjoy teaching motivated patients to fully care for their dialysis needs at home and embrace any new technology or methods to help them achieve their goals and maintain their independence.

Integrated care, hospital to community: Improving patient journey

Ms Glenda Rayment1, Ms Charity Omwoyo, M Susana Sanmiguel, Ms Karina Castro

1Liverpool Hospital, Liverpool, Australia

Introduction

PD is a mode of renal replacement therapy performed in the home that has several advantages compared to hospital-based dialysis such as flexibility and freedom. Peritonitis is the major cause of technique failure for PD, with adherence to antibiotic therapy essential for resolution.  An innovative model of care was developed and implemented in 2016 between a tertiary referral hospital and Community Health services for the management of peritonitis.

Aim

The aim of this project was to effectively manage PD-related peritonitis in the home, utilising the existing health system resources, overall promoting adherence to antibiotic therapy and decreasing hospital length of stay (LOS).

Context

This is a 3 – year review of Community Health Service involvement in managing PD-related peritonitis at home. Over this period, there were 365 PD-related peritonitis presentations with an average of 121 presentations per year, of which over 70% were treated in their homes utilising the Community Health Service. During this 3 -year period, there were a total number of 257 referrals to Community Health Service, with an average of 85 referrals per year.

Conclusion

This model of care effectively utilized existing resources within the health system to improve patient outcomes by integrating patient care from the hospital to the community health sector. This has also increased patient adherence to antibiotic treatment due to the convenience of administering antibiotics in the patient’s homes, and also reduced hospital LOS by approximately 3598 bed days over the 3 year period.


Biography:

Charity Omwoyo is the Nurse Practitioner in the Renal Home Therapies Unit. Charity has worked previously as an NP in CKD. Charity has worked in Renal units across Australia and also has international experience working in the USA and Kenya. In her spare time, Charity is undertaking a degree in Law.

Slow and steady wins the race

Dr Franziska Pettit1, Sr Yasko  Takatori1,2, Sr  Kylie Turner1

1St George Hospital Sydney, Kogarah, Australia, 2Sydney Dialysis Centre, Royal North Shore Hospital, Australia

Introduction: Advanced age, difficult vascular access and non-English speaking status are common reasons for not choosing a home dialysis therapy. I present two cases where these barriers were overcome successfully.

Case 1: EB was an 81 year old married woman who had had extensive education on her options as she was nearing end stage renal disease. She chose haemodialysis as her modality of choice and had a left braciocephalic atrerio-venous fistula created. She was adamant that she and her husband would do this therapy at home. Training in her case was slow compounded by her access which was deep and placed in her dominant arm. After 8 months of training EB and her husband went home and have not required a hospital admission since – three years and counting.

Case 2: TT was a 74 year old man on peritoneal dialysis which was failing. A decision was made to transition him to home haemodialysis, as he was accustomed to a home therapy. Neither TT nor his wife, who was his support person, spoke much English but with the assistance of their daughter and a formal interpreter the dialysis handbook was translated into their native tongue. Again here training was slow due to age and the language barrier but after 8 months TT was discharged home and has avoided hospitalisation since.

Conclusion: Age, difficult access and language are barriers which can be overcome if given enough time and patience. The rewards for the patients and physicians are great.


Biography:

Dr Franziska Pettit is a nephrologist and obstetric medicine physician who works full time at St George Hospital in Sydney’s south. There she is the director of the Peritoneal Dialysis unit and has a large number of both chronic kidney disease, dialysis and transplant patients. Her research interests lie in the field of obstetric medicine and hypertension and she has presented and published widely in this field. She has a passion for providing the best care in the right setting for her dialysis patients. She is also the co-director of physician’s training at St George and holds a conjoint lecturer position at UNSW.

Peritoneal Dialysis: a Viable Therapy Following Ventricular Assist Device Implantation

Mr Kye Manefield1

1Alfred Health, Melbourne, Australia

End-stage kidney disease is a common complication of Cardiorenal Syndrome. Dialysis management in this setting is challenging due to haemodynamic instability which limits conventional dialysis and ultrafiltration delivery. Although patient complexity, instrumentation (particularly Ventricular Assist Devices [VADs]), and accompanying transperitoneal drivelines present a barrier to uptake, we describe the successful application of peritoneal dialysis (PD) in this context.

In 2018, a 62-year-old male with end-stage non- obstructive dilated hypertrophic cardiomyopathy underwent a VAD implantation. Renal function deteriorated in the setting of post-operative decompensated heart failure, necessitating continuous haemofiltration in ICU, followed by transition to conventional intermittent high-flux haemodialysis (HDx). The patient failed to thrive on HDx, suffering from ongoing lethargy alongside repeated symptomatic cardiac decompensation (mean arterial pressure (MAP) < a target of 58mmHg) necessitating urgent clinical reviews. After considering alternatives, a Tenckhoff catheter was placed percutaneously and the patient was commenced on PD.

Several key benefits were quickly manifest from this change of modality. Firstly, PD allowed for a supportive care giver model to be used in which the patient’s wife was trained in PD exchanges- allowing the patient the option of dialysing at home. Secondly, PD supported cardiac function, reliably achieving MAP between 70-94mmHg. Following improvements in fluid state, energy levels, nutrition and global function, the patient progressed to candidacy for combined heart-kidney transplantation.

This case study illustrates the potential benefits of PD in patients at risk of cardiac instability, supporting its role as a viable treatment option for the complex patient with Cardiorenal Syndrome.


Biography:

Biographies to come

The grace of empowerment

Mr Matthew Harvey, Dr Louis  Huang, Mrs  Peta McLean, Mrs Dong Wang, Mr Lionel Holt

1Eastern Health, Box Hill, Australia

Introduction

Mr H is a 73 year old who has been on satellite haemodialysis for 5 years. The physical limitations of osteoarthritis affecting his mobility, ability to drive and manage his rural property, combined with the scrutiny of diet, fluid consumption, weight gain, monthly pathology and medications that is standard satellite management contributed to an ever increasing tension between Mr H and dialysis staff. The situation became untenable.

Method

In response to increasing verbal aggression from Mr H, the resultant unplanned leave for staff and patient complaints of dissatisfaction with their dialysis experience a multi-disciplinary approach was taken to initially de-escalate, find the root cause and create a plan to improve Mr H’s overall health, dialysis regimen and quality of life. Regular consultation over several months uncovered contributing factors to rising frustrations and identified his desire to attempt haemodialysis at home.

Results

Despite many barriers to dialysing at home including limited mobility, isolation in a high-risk bushfire zone, a non-English speaking partner and regular power outages, Mr H and the EH Home Dialysis Team pushed on with training and after 3 months Mr H had his first independent run at home.

Conclusion

Mr H has been dialysing independently at home for 7 months and with control over his diet/fluid intake, weight gain and dialysis hours he is experiencing a greater sense of purpose, increased time at home with his wife, improved level of trust in healthcare professionals and a greater quality of life.


Biography:

Matt has been nursing for 25 years predominantly in the Medical Specialties of Renal, Neurology, Stroke and Endocrine. After completing a Nursing Graduate Program at Alfred Health in 1995, he held positions as Associate Unit Manager and Clinical Support & Development Nurse, before taking up a position as Nurse Educator at Eastern Health soon after the opening of the new Eastern Health Integrated Renal Service in 2009. For the past 8 years, Matt has worked as a Nurse Unit Manager currently leading the Home Dialysis Service at Eastern Health and has a passion for great patient outcomes.

Advance care planning for patients with end-stage kidney disease: A local perspective

Ms Wendy Gibson1,2, Mrs.  Bharati Mehta1,3

1Renal Supportive Care – Western Renal Service, Blacktown, Australia, 2Renal Society of Australiasia, NSW, Australia, 3Australian Association of Social Workers, NSW, Australia

ACP is a process of discussions concerning patients’ values, their Goals of Care (GOC) and their End of Life (EOL) wishes.  Ideally, it should involve patients, their families and carers and their professional care providers in a shared decision-making process.  A procedural guideline has been developed to guide staff undertaking ACP for patients with ESKD either receiving Renal Replacement Therapy or on a Conservative Pathway.

The first step of this guideline is to enhance the comfort level of Renal Staff discussing values, GOC and EOL wishes with patients.  It is important to recognise that, even with training, not all staff feel comfortable initiating these discussions.  A referral pathway has been designed so that these staff can refer patients to other clinicians more comfortable in initiating these discussions.

Our goal is to raise the subject of ACP with all patients with ESKD.  A proportion may progress to a written document, an Advance Care Directive (ACD).  At the very least, we aim that patients’ families and carers have insight into their loved ones’ values, GOC and EOL wishes.  ACP and ACDs reduce stress in bereaved relatives.


Biography:

Wendy Gibson

Wendy has been working in Nephrology since 1998 and has a variety of experience in the field,  since 2002 to 2017 worked in haemodialysis. In 2017 she started working in Renal Supportive Care, and has developed an interest in how the workforce approaches and implements  Advanced Care Planning.

She also has worked as a Clinical Nurse Educator for 7 years in haemodialysis.

Wendy has presented at the Renal Society of Australasia and the Nephrology Educators Network Symposium, she has also a founding member and Board Member of The Nephrology Educators Network.

 

Bharati Mehta

Bharati is a Renal Supportive Care Senior Hub Social Worker for

Western Renal Services working with patients across western Sydney and Nepean Blue Mountains local health districts since last four years. She has acquired Master’s degree in Social Work, with 25 years of extensive work experience working in the field of Social Work. She is a current member of Australian Association of Social Worker. She has worked as a mental health specialist clinician and with Ageing and Disability in the past.

Patients with end-stage kidney disease (ESKD) experience a high symptom burden and increased morbidity and mortality rates when compared to those with other diagnoses.  Many older patients, especially those with multiple comorbidities, don’t achieve any improvement in function or longevity with Renal Replacement Therapy.  Advance Care Planning (ACP) is often delayed until the approach of the end of life.

About ANZSN

The ASM is hosted by Australian and New Zealand Society of Nephrology.

The aims of the Society are to promote and support the study of the kidney and urinary tract in health and disease, and to ensure the highest professional standards for the practice of nephrology in Australia and New Zealand.

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