What are PROMS and why are they relevant to the home dialysis population?

Dr Alice Kennard1 

1Canberra Health Services, ACT, Australia

An exploration of the role of PROMs (patient reported outcomes) and PREMs (patient reported experience measures) in optimising quality of life and patient-centred care in the home setting

 


Biography: 

Dr Alice Kennard is an early-career nephrologist with an interest in renal supportive care and palliative care. She currently beginning research in the areas of frailty, quality of life and the dialysis caregiver experience as part of a PhD.  Alice has trained in several Australian Renal Units and has a passion for improving equity and high quality care for people with kidney disease. Alice is responsible for the service development and delivery of The Canberra Hospital’s Renal Supportive Care program.

Developing Peritoneal Dialysis in Fiji: the Role of Interventional Nephrology

Dr Eddie Tan1, Dr Amrish Krishnan2, Ms Sarita Goundar2, Dr Gerald Waters1

1Waikato Hospital, Hamilton, New Zealand, 2Fiji Kidney Hub, Suva, Fiji

Introduction:

End-stage kidney disease is a huge problem in Fiji. Haemodialysis is not free and prohibitively expensive, so promoting the cheaper (but under-developed) alternative, Peritoneal Dialysis (PD), is the only viable cost-effective dialysis option.  The growth of a PD program relies heavily on developing physician-led PD Catheter (PDC) Insertion (PDCI) skills.

Methods:

We looked at how PD developed in Fiji over time: 2015-2019 (present), coinciding with overseas interventional nephrologists visits. There were PD-related lectures (e.g. PD prescription, acute PD, PDCI techniques) and PDCI demonstrations with hands-on sessions using models/phantoms incorporating pork bellies. This culminated in 2019 with a 1-day PD workshop (lectures and practice PDCI sessions) and 2-day supervised PDCIs in live patients. The work involved preparing talks, assembling teaching materials, arranging paperwork (e.g. local medical council registration and indemnity cover), seeking sponsorship and liaising with local teams (physicians, surgeons and nurses).

Results:

Initially there were no PD patients and very little PD skill-sets locally. Interest in PD has since increased with enhanced PD skill-sets (via overseas secondments of local doctors/nurses and training visits by PD teams from abroad) and newly-sourced government-sponsored infrastructure to develop PD (premises, equipment and personnel). Local feedback for the mentoring/sessions is extremely positive with reported increased confidence in PD knowledge and PDCIs. 2 local physicians received direct supervision in PDCIs on local patients.

Conclusions:

Enthusiasm and knowledge in PD has mushroomed in Fiji. Further supervised PDCIs could help establish independent PDCIs locally; helping develop PD as a cheaper, viable dialysis alternative to save more lives.


Biography:

Ms. Sarita Goundar is a dialysis nurse in the Fiji Kidney Hub.

Hybrid dialysis is a viable option to extend peritoneal dialysis technique survival

Dr Mandy Law1, Ms Jill Bone1, Mr Matthew Harvey1, Ms Angela Daffey1, Ms Anne-Marie Desai1, Ms Jo Englezos1, Professor Lawrence P McMahon1,2, Dr Louis Huang1,2

1Department of Renal Medicine, Eastern Health, Box Hill, Australia, 2Monash University, Clayton, Australia

Introduction

Hybrid dialysis by adding weekly haemodialysis (HD) to peritoneal dialysis (PD) may be a suitable strategy to improve solute and fluid clearance whilst keeping patients home to maintain quality of life. There is limited reporting of the use of hybrid dialysis in Australia.

Method

This is a retrospective review of a single-centre approach to identifying PD patients with inadequate therapy (total CrCl <70 L/week, or Kt/V <1.7 and symptomatic) and the multidisciplinary support to extend PD technique survival. Baseline assessments of symptoms using POS-S Renal, DASS21 and PHQ9, NSQOL and MIS instruments were performed by PD nurses, social worker, psychologist and dieticians.

Results

Thirteen patients were assessed as suitable for hybrid dialysis and have extended PD technique survival in 11 patients by 6 [range 1-24]months. Median total CrCl and Kt/V prior to commencement of hybrid dialysis were 60.4 [56.5-62.8]L/week and 1.9 [1.7-2.1], respectively. The most common symptoms reported on the POS-S Renal were ”weakness”,  “drowsiness”, “itch” and “difficulty sleeping”. Depressive symptoms were common (72-86%). Nine patients started hybrid therapy using an arteriovenous fistula (AVF), whilst 2 started via permacaths.  Two patients had AVF created but received kidney transplantation prior to starting hybrid dialysis. Five patients ceased hybrid therapy for reasons including peritonitis, inadequate solute removal and withdrawal. Two patients received kidney transplantation. Four patients remain on hybrid dialysis with one having extended technique survival by 24 months.

Conclusion

Hybrid dialysis is suitable in select patients to improve dialysis adequacy and maintain quality of life, whilst extending PD technique survival.


Biography:

Biography to come

Tunneled Haemodialysis Catheter use in home haemodialysis setting

Dr Jeffrey Wong1, Dr Tim Spicer1, Susana San Miguel1, Glenda  Rayment1

1Liverpool Hospital, Sydney, Australia

Aim:  Tunnelled haemodialysis catheters(TVC) are considered inferior to arteriovenous fistulae(AVF) and grafts(AVG) in centre dialysis settings. Less is known of their role in home haemodialysis(HHD) where concerns may be amplified excluding TVC patients from HHD training and require trained HHD patients to dialyse in centre during periods of permanent access dysfunction. Here we describe our experience of TVCs in the HHD setting.

Methods: Retrospective review of TVCs in HHD from 2013- 2019. Patients were identified from home therapies database. Patient details, catheter details and outcomes were obtained from electronic medical records(eMR) and letters.

Results:   Twenty three TVCs were used in 21 HHD patients. Five patients commenced HHD with permanent accesses (4AVF, 1AVG) and received bridging TVCs for access malfunction at a median of 1168[IQR 612-1880] days after HHD commencement. These TVCs was used for a median of 121[IQR 49-189] days. Sixteen patients commenced HHD training with a TVC. These were used for a median of 228[IQR 130-322] days, significantly longer than the group trained with permanent access p=0.015.  TVC was the intended permanent access for 1 patient which continues to function after 1941 days. Adverse outcomes include: 1 suicide by cutting TVC and 2 episodes of Staph aureus bacteraemia giving a bacteraemia rate of 0.28/1000 catheter days.

Conclusions:  TVCs may be used successfully for both bridging access and for commencement of training in HHD where the duration of TVC use may be longer. In select cases where permanent access cannot be created for HHD a permanent TVC deserves consideration.


Biography:

Biographies to come

Understanding the communication needs of home haemodialysis patients through remote monitoring systems

Ms Mary Ann Nicdao1

1Western Renal Service, Blacktown, Australia

Background: Decreased face to face consultations between patients and healthcare professionals may bring feelings of isolation which may be detrimental to patients’ emotional well-being.  Remote monitoring is increasingly being utilised for home haemodialysis (HHD) patients due to its evident benefits in allowing patients to record their dialysis parameters as well as send messages about their dialysis sessions. This study aimed at understanding the communication needs of patients who were experiencing technical difficulties related to haemodialysis sessions at home.

Methods: Thematic contents were analysed using machine learning tools on 1,238 text messages sent by 52 patients via a dialysis remote monitoring system from 1 Jan 2015 to 30 Jun 2018. Technically-troubled dialysis treatments were defined as those sessions where there was >5% difference between patients’ post dialysis weight and the recommended dry weight (RDW); > 5% difference in ultrafiltration goal and RDW, and when there was >1% standard deviation between actual and mean arterial and venous pressures.

Results: Preliminary findings show that the predominant theme was ‘outcome-oriented’, which described patients’ feelings during or after dialysis. The second major theme was ‘context-oriented’ which provided useful information regarding patients’ regular medications and vascular access interventions. ‘Measurement’ theme was the third largest, which reported on health metrics such as blood pressure and pulse rate. The least frequent theme was ‘complication’ which conveyed of any intradialytic issues.

Conclusions: Patients on HHD were able to report dialysis session outcomes to health professionals, followed by contextual information and measurement of parameters through a remote monitoring app.


Biography:

Biographies to come

A prospective randomised controlled trial of incremental haemodialysis – INCH-HD. Trial protocol

Dr Martin Wolley1, Dr  Andrea Viecelli2,4, Donna Reidlinger4, Professor David Johnson2,4, Nicole Scholes-Robertson5, Professor Matthew Roberts3, Professor Carmel Hawley2,4

1Department of Renal Medicine, Royal Brisbane And Women’s Hospital, Brisbane, Australia, 2Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia, 3Eastern Health Clinical School, Monash University, Melbourne, Australia, 4Australasian Kidney Trials Network, Brisbane, Australia, 5Centre for Kidney Research, Children’s Hospital at Westmead, Westmead, Australia

Introduction:

Incident haemodialysis patients typically commence dialysis thrice weekly. Observational evidence suggests however that incremental haemodialysis (starting at <3/week and increasing as needed) is associated with at least equivalent mortality outcomes and may be associated with preservation of residual kidney function (RKF). Incremental HD has never been subject to a prospective randomised controlled trial (RCT) and robust safety data are needed before it can be advocated.

Methods:

The INCH-HD will be a multi-centre RCT randomising suitable patients to start conventional (3/week) or incremental (2/week) haemodialysis. Focus groups will decide on the primary outcome, with options including loss of RKF, health related quality of life and symptom scores. Secondary outcomes include safety and cost analysis. RKF and triggers to increase dialysis frequency are assessed monthly and other outcomes 3 monthly for a planned 18 month follow up period. A feasibility survey assessing clinician attitudes was performed in 2019.

Results:

If powered for loss of RKF 150 participants are needed (predicted HR 0.6 for incremental vs conventional). The ANZSN survey had 22 respondents of whom 57% already start patients on incremental HD and most expect patients to be on 2/week HD for 3-6 months prior to increasing. Most respondents (60%) were willing to randomise suitable patients to INCH-HD, suggesting feasibility to achieve enrolment targets.

Conclusion:

Incremental HD is an attractive concept which may offer benefits to RKF and quality of life outcomes as well as cost savings with acceptable safety. A prospective trial assuring safety is urgently needed and will be addressed with INCH-HD.


Biography:

To come

Spreading the word: How renal integration in the Top End has doubled home therapies intake in less than 2 yrs

Mrs Amanda Elzini1

1Top End Health Service, Darwin, Australia

Introduction

In an ever-increasing demand for service, a stronger focus on Renal Home Therapies (RHT) was required in the Top End.  With difficulties in maintaining service due to need exceeding availability, RHT moved from the satellite service umbrella into its own branch with a dedicated manager.  By November 2018, RHT was able to relocate to one building to provide CKD, PD, HHD, Transplant, and Supportive care under one roof.  With better access to resources, focus on pathways to home and a multi-disciplinary approach to care, RHT has seen a spike in interest and clients utilising the home therapy model of care.

Method

Key Performance Indicators were developed and consumer engagement actioned

Results

Discussion of results will include and not limited to:

  • An increase of 30% of CKD Stage 5 patients who had AV-Fistula or tunnelled line access created in preparation for RRT.
  • An increase of 50% in the total number of PD patients undertaking treatments at home or in the community.
  • An improvement in the number of patients attending PD education sessions

Conclusion

The creation of RHT has supported an increase in referrals and use of service.  Since opening, RHT has demonstrated the benefits of co-locating the CKD nurse with home based therapies and positively influenced the patients and their journey, through improvement in patient flow and integration of service.


Biography:

Amanda has been working in Renal for the last 17 years, completing both a Post Graduate Certificate in Nephrology Nursing and a Masters Degree in Nursing.  Amanda has worked throughout Australia and the Middle East during her career, primarily in the Haemodialysis space.  Amanda has had the privilege of managing Renal Health Centres across the Kimberley and was an active member in the design and development of Renal Hostels and new renal unit builds in the Kimberley.  A passion for Aboriginal health and providing care closer to home, Amanda took on the newly appointed position role of Renal Home Therapies with Top End Renal Services in early 2018.  It has been an exciting and challenging time with many changes needed to the approach to care and improving patient pathways home.  Amanda has been able to accomplish key strategies with the support of a fantastic Renal Home Therapies team!

Quality of life in patients receiving standard and extended hours haemodialysis versus quality of life of their caregivers: a secondary analysis of the Co-ACTIVE sub-study of the ACTIVE dialysis trial

Dr Melissa Nataatmadja1,2, Assoc Prof Rathika Krishnasamy1,2,3, Dr Li Zuo4, Dr Daqing Hong5, Dr Brendan Smyth6,7,8, Dr Min Jun6, Dr Janak de Zoysa9,10, Prof Kirsten Howard7, Dr  Jing Wang11, Dr Chunlai Lu12, Dr Zhangsuo Liu13, Prof Chris Chan14, Prof Alan Cass15, Prof Vlado Perkovic6, Assoc Prof Meg Jardine6,16, Assoc Prof Nicholas Gray1,2

1Department of Nephrology, Sunshine Coast University Hospital, Birtinya, Australia, 2Faculty of Medicine, University of Queensland, Herston, Australia, 3Australasian Kidney Trials Network, Woolloongabba, Australia, 4Peking University People’s Hospital, Beijing, China, 5Sichuan Provincial People’s Hospital, Chengdu, China, 6The George Institute for Global Health, Sydney, Australia, 7Sydney School of Public Health, University of Sydney, Sydney, Australia, 8Department of Renal Medicine, St George Hospital, Sydney, Australia, 9Renal Service, Waitemata District Health Board, Auckland, New Zealand, 10Department of Medicine, University of Auckland, Auckland, New Zealand, 11Department of Nephrology, First Affiliated Hospital of Dalain Medical Univeristy, Dalain, China, 12Department of Nephrology, Shanghai 85th Hospital, Shanghai, China, 13Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China, 14Division of Nephrology, University Health Network, Toronto General Hospital, Toronto, Canada, 15Menzies School of Health Research, Charles Darwin University, Darwin, Australia, 16Department of Renal Medicine, Concord Repatriation General Hospital, Sydney, Australia

Clinicians may advocate for extended hours dialysis due to perceived benefits for the patient, however little is known about its effects on caregivers.

Participants were randomised to receive extended (median 24 hours/week) or standard (12 hours/week) haemodialysis for 12 months in the ACTIVE Dialysis trial. In this sub-study, participants  nominated a carer who was invited to participate in an assessment of QOL and carer impact. Patients and their caregivers completed the EuroQOL-5 Dimension-3 Level (EQ5D-3L), Short Form-36 (SF-36) physical component summary (PCS), mental component summary (MCS) and SF-6D and differences between patients and carers were evaluated using Wilcoxon rank-sum test.

A total of 40 patient-caregiver pairs participated in the Co-ACTIVE sub-study, including 34 from China. There was no significant difference in change in EQ5D from baseline to follow-up between patients and caregivers in either the standard hours (0.005±0.27 vs -0.02±0.16, p=0.97) or extended hours groups (-0.04±0.16 vs -0.18±0.30, p=0.06 ). Similarly, there were no differences between the patients and caregivers respectively in mean change in scores, in those randomised to either standard hours [SF-36 PCS (0.21±6.5 vs -5.34±8.77, p=0.16); MCS (0.5±9.35 vs -2.21±8.68, p=0.62), SF-6D (0.0003±0.12 vs -0.037±0.096, p=0.63)] or extended hours [SF-36 PCS (-0.66±8.41 vs -1.06±9.28, p=0.6); MCS (-0.5±8.25 vs -4.11±11.63, p=0.34), SF-6D (-0.02±0.12 vs -0.03±0.12, p=0.8)].

There were no significant differences between patients and caregivers in change in QOL or health utility over time, in either standard or extended hours dialysis. Further work is needed to examine the impact of extended hours haemodialysis on caregivers.


Biography:

Melissa completed her medical training at the University of Queensland and trained in nephrology at the Gold Coast University Hospital and Princess Alexandra Hospital before moving to Vancouver, Canada to complete her training and undertake a home dialysis fellowship. She is now working as a nephrologist at the Sunshine Coast University Hospital, and is a PhD candidate studying quality of life and clinical outcomes in patients on home dialysis.

Risk predictors of technique failure and mortality in peritoneal dialysis in New Zealand: An analysis of the New Zealand Peritoneal Dialysis Registry Data.

Dr Ashik Hayat1

1Taranaki District Health Board, NewPlymouth, New Zealand

MD DM FRSCP FASN FACP MPH

Peritoneal dialysis (PD) is now the established and clinically equivalent therapy to hemodialysis, in patients with End Stage Kidney disease.

The aim of the present study is to analyze, the demographic and the clinical risk predictors of the death-censored technique failure and mortality in patients on PD in New Zealand.

Demographic and clinical data were collected from the New Zealand Peritoneal dialysis registry NZPDR from 1st January 1995 to 31st December 2014. Crude rates for technique failure and mortality were calculated. Cox proportional hazards regression model was generated to evaluate for the risk predictors of technique failure and mortality. Hazards of technique failure and mortality were compared between two decades of follow up, to examine for the time trends.

Of the 6379 patients studied, there were 2993 (46.9%) episodes of technique failure and 2684 (42%); deaths recorded over two decades of follow up. The crude death-censored technique failure rates were mean ± SD, of 165 ± (SD = 5.90) per 1000 patient years of the follow up.  The mortality rates were mean ± SD, of 147.9 ± (SD= 5.50) per 1000 patient years of follow up. Two and 5-year death-censored technique survival rates were 67% and 17.5% respectively; while as the 2 and 5-year patient survival rates were 70.42% and 26% respectively. Crude rates and hazards of technique failure were lower in individuals older than 60 years, compared to younger individuals, with a HR of 0.72 (95% C.I. 0.67-0.79), p value <0.001. The Crude rates and the hazards of death in individuals older than 60 years were higher compared to younger individuals with a HR of 2.13, (95% CI 1.91-2.46), p value <0.001. Coiled catheters were associated with a higher technique failure rates, with a HR 1.26 (95% CI 1.16-1.37), p value, of <0.001. Larger centres were associated with a lower incidence of the death-censored technique failures, with HR 0.89, (95% CI 0.79-1.00), p value of 0.06. Technique failure and mortality rates were noted to be lower in the Asian and Pacifica ethnicities compared to European / Pakeha. Infections were the major causes (58.4%) of technique failure, with acute peritonitis contributing to 30.2%. Higher New Zealand deprivation index score, male gender, and non-Asian ethnicities were associated with poorer survival on PD.

Optimum management of the modifiable risk factors can improve the patient and technique survival on PD.


Biography:

Consultant department of Nephrology Taranaki Base Hospital New Zealand

Acetic acid dressing for pseudomonas exit site infection in peritoneal dialysis patients: Single centre experience

Ms Youn Park1, Mrs Natividad Miles1, Mrs Carmen Moroney CNS Moroney1, Mr  Thanh Bui1, Mr  Shanes Morgan1, Dr John Saunders1, Dr  Paul Snelling1

1Royal Prince Alfred Hospital, Sydney, Australia

Background: Pseudomonas exit site infection (ESI) often results in catheter removal despite intensive antibiotic treatment. Our peritoneal dialysis (PD) unit experienced repeated episodes of pseudomonas ESI. We report pseudomonas infection rates of in PD patients (pts) before and after using 2.5% acetic acid dressing (AAD) for infected exit site with Pseudomonas.

Aim: To analyse the effectiveness of 2.5% acetic acid use for infected Pseudomonas ESIs

Methods: This observational Cohort study analysed pseudomonas ESI episodes between 2017 and 2019. We compared three groups with Pseudomonas ESIs using different antiseptic agents. Group 1 – Standard dressing (SD) only, Group 2-SD first and later change to AAD, Group 3- AAD only. All patients received standard oral antibiotics as our unit ESI policy. There were 18 patients with follow-up 20.9 patient years; 10 pts in Group 1 for 8.9 years, 3pts in Group 2 for 7.3 years (SD 3.5 years: AAD 3.8 years) and 5pts in Group 3 for 4.6 years.

Results: 28 Pseudomonas ESIs developed in 18 pts; 6 patients had 1-3 repeated Pseudomonas ESIs.  Group 1 developed 5 repeated Pseudomonas ESIs in 4pts after initial Pseudomonas ESI, Group 2 developed 5 repeated ESIs in 3pts during the SD period. No repeated pseudomonas ESIs were recorded in Group 2 after AAD and no repeat ESI occurred in Group 3.

Conclusion: Repeated Pseudomonas ESI rates can be reduced using 2.5% acetic acid for chronic ES dressing. Acetic acid PD dressing use to eradicate Pseudomonas ESIs merits further investigation.


Biography:

Youn Park has more than 35 years of renal experience and now works as a Home Therapies Clinical Nurse Consultant at Royal Prince Alfred Hospital and Concord Repatriation General Hospital, Sydney.

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