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Admission rates stratified by dialysis pattern. Hemodialysis (HD1) represents Monday in a patient dialyzing on a Monday/Wednesday/Friday (Mon/Wed/Fri) regime, Tuesday in a patient who dialyzes on a Tuesday/Thursday/Saturday (Tue/Thu/Sat) regime, and Sunday in patients who dialyzed on a Tuesday/Thursday/Sunday (Tue/Thu/Sun) regime. The day after the first HD session was assigned HD1a, HD2 for the second HD session etc. Irrespective of dialysis pattern, HD1 was always the day after the long gap.
Source publication
Excess mortality and hospitalization have been identified after the 2-day gap in thrice-weekly hemodialysis patients compared with 1-day intervals, although findings vary internationally. Here we aimed to identify factors associated with mortality and hospitalization events in England using an incident cohort of 5864 hemodialysis patients from year...
Contexts in source publication
Context 1
... was an increase in admissions after the long break (2.38 per year for the first HD session of the week, HD1 vs. 1.40 per patient year for the rest of the week; ratio of admission rates (RR) 1.69, 95% confidence interval (CI) 1.63-1.76: Po0.001), which was observed for both Mon/Wed/Fri, Tue/Thu/Sat, and Tue/Thu/ Sun patients (Figure 1). Admission rates for HD3 for Mon/ Wed/Fri (Friday) and Tue/Thu/Sat (Sat) patients were similar (1.67 and 1.71 admissions per year, P = 0.4995). ...
Context 2
... increased admission rate approaching death was greater in those dying in-hospital compared with patients dying out-of-hospital; however, the association with the long gap was weaker. A greater increase in admissions after the long gap prior to death was seen in those who subsequently died out-of-hospital (Supplementary Figure S1 online). The patterns of both admission rates and mortality were similar in summer (April to September) and winter (October to March). ...
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Methods
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Introduction
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Methods
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Citations
... 8 9 Previous work linking data from the UK Renal Registry (UKRR) with Hospital Episode Statistics (NHS secondary care data) showed that using only Hospital Episode Statistics to identify ongoing chronic dialysis was satisfactory in only a subgroup of English centres, because not all centres reported dialysis consistently. 9 OpenSAFELY is a secure, health analytics platform, set up to monitor the effect of covid-19 on health outcomes. OpenSAFELY contains electronic health records from general practices covering 40% of the population of England. 10 Because of the risks related to covid-19 disease, correctly identifying people receiving kidney replacement therapy when analysing data on vaccination 11 and antiviral treatment is important. ...
Objective
To validate primary and secondary care codes in electronic health records to identify people receiving chronic kidney replacement therapy based on gold standard registry data.
Design
Validation study using data from OpenSAFELY and the UK Renal Registry, with the approval of NHS England.
Setting
Primary and secondary care electronic health records from people registered at 45% of general practices in England on 1 January 2020, linked to data from the UK Renal Registry (UKRR) within the OpenSAFELY-TPP platform, part of the NHS England OpenSAFELY covid-19 service.
Participants
38 745 prevalent patients (recorded as receiving kidney replacement therapy on 1 January 2020 in UKRR data, or primary or secondary care data) and 10 730 incident patients (starting kidney replacement therapy during 2020), from a population of 19 million people alive and registered with a general practice in England on 1 January 2020.
Main outcome measures
Sensitivity and positive predictive values of primary and secondary care code lists for identifying prevalent and incident kidney replacement therapy cohorts compared with the gold standard UKRR data on chronic kidney replacement therapy. Agreement across the data sources overall, and by treatment modality (transplantation or dialysis) and personal characteristics.
Results
Primary and secondary care code lists were sensitive for identifying the UKRR prevalent cohort (91.2% (95% confidence interval (CI) 90.8% to 91.6%) and 92.0% (91.6% to 92.4%), respectively), but not the incident cohort (52.3% (50.3% to 54.3%) and 67.9% (66.1% to 69.7%)). Positive predictive values were low (77.7% (77.2% to 78.2%) for primary care data and 64.7% (64.1% to 65.3%) for secondary care data), particularly for chronic dialysis (53.7% (52.9% to 54.5%) for primary care data and 49.1% (48.0% to 50.2%) for secondary care data). Sensitivity decreased with age and index of multiple deprivation in primary care data, but the opposite was true in secondary care data. Agreement was lower in children, with 30% (295/980) featuring in all three datasets. Half (1165/2315) of the incident patients receiving dialysis in UKRR data had a kidney replacement therapy code in the primary care data within three months of the start date of the kidney replacement therapy. No codes existed whose exclusion would substantially improve the positive predictive value without a decrease in sensitivity.
Conclusions
Codes used in primary and secondary care data failed to identify a small proportion of prevalent patients receiving kidney replacement therapy. Codes also identified many patients who were not recipients of chronic kidney replacement therapy in UKRR data, particularly dialysis codes. Linkage with UKRR kidney replacement therapy data facilitated more accurate identification of incident and prevalent kidney replacement therapy cohorts for research into this vulnerable population. Poor coding has implications for any patient care (including eligibility for vaccination, resourcing, and health policy responses in future pandemics) that relies on accurate reporting of kidney replacement therapy in primary and secondary care data.
... 12 One of the challenges with in-centre haemodialysis is the 2-day-long gap that occurs with thrice-weekly sessions spread over 7 days. 13 This inter-dialytic gap is associated with increased mortality and hospitalisation, but can be overcome by the use of alternate-day dialysis at home. ...
Home dialysis therapies offer a significant benefit to patients in respect of quality of life and autonomy, as compared with in-centre haemodialysis. There is significant unwarranted variation across the world in the availability of both peritoneal dialysis (PD) and home haemodialysis, which has led in the UK to a recommendation of a minimum 20% prevalent rate of dialysis patients at home. Key advances in PD have included changes in the approach to prescribing PD and the use of assisted dialysis. Peritonitis remains a significant complication which may present to general physicians and needs prompt recognition and treatment. The development of novel small dialysis machines has led to a resurgence of interest in home haemodialysis.
... It is well established that a long-dialysis break is associated with several poor health outcomes such as increased risk of death, 26,27 ED visits, 28 and hospitalizations. 29 Analysis of our secondary outcomes showed that there were differences in hospital admission between those patients requiring urgent dialysis and those who did not. Interestingly, urgent dialysis patients had a reduced median length of stay compared to other patients, which may be a result of the acute nature of events such as hyperkalemia that can be quickly treated without the need for prolonged stay. ...
Background
Patients receiving maintenance hemodialysis frequently require ambulance transport to the emergency department (ambulance-ED transport). Identifying predictors of outcomes after ambulance-ED transport, especially the need for timely dialysis, is important to health care providers.
Objective
The purpose of this study was to derive a risk-prediction model for urgent dialysis after ambulance-ED transport.
Design
Observational cohort study
Setting and Patients
All ambulance-ED transports among incident and prevalent patients receiving maintenance hemodialysis affiliated with a regional dialysis program (catchment area of approximately 750 000 individuals) from 2014 to 2018.
Measurements
Patients’ vital signs (systolic blood pressure, oxygen saturation, respiratory rate, and heart rate) at the time of paramedic transport and time since last dialysis were utilized as predictors for the outcome of interest. The primary outcome was urgent dialysis (defined as dialysis in a monitored setting within 24 hours of ED arrival or dialysis within 24 hours with the first ED patient blood potassium level >6.5 mmol/L) for an unscheduled indication. Secondary outcomes included, hospitalization, hospital length of stay, and in-hospital mortality.
Methods
A logistic regression model to predict outcomes of urgent dialysis. Discrimination and calibration were assessed using the C-statistic and Hosmer-Lemeshow test.
Results
Among 878 ED visits, 63 (7.2%) required urgent dialysis. Hypoxemia (odds ratio [OR]: 4.04, 95% confidence interval [CI]: 1.75-9.33) and time from last dialysis of 24 to 48 hours (OR: 3.43, 95% CI: 1.05-11.9) and >48 hours (OR: 9.22, 95% CI: 3.37-25.23) were strongly associated with urgent dialysis. A risk-prediction model incorporating patients’ vital signs and time from last dialysis had good discrimination (C-statistic 0.8217) and calibration (Hosmer-Lemeshow goodness of fit P value .8899). Urgent dialysis patients were more likely to be hospitalized (63% vs 34%), but there were no differences in inpatient mortality or length of stay.
Limitations
Missing data, requires external validation.
Conclusion
We derived a risk-prediction model for urgent dialysis that may better guide appropriate transport and care for patients requiring ambulance-ED transport.
... 11,12 In these patients, excessive fluid volume is associated with an increase in the hospitalization rate and high morbidity and mortality. [13][14][15][16] Moreover, its occurrence causes serious health problems in this clientele, such as worsening and increased prevalence of cardiovascular diseases, 17,18 in addition to restrictive and obstructive respiratory abnormalities, such as acute pulmonary edema. 19,20 Therefore, it is verified that excessive fluid volume is an important nursing problem in the progression of adverse clinical outcomes in patients undergoing hemodialysis. ...
... Incomplete fluid withdrawal in hemodialysis determines the residual volume, so that it directly interferes with dry weight at the end of hemodialysis. 13,16 Although similar, water retention and interdialytic weight gain are not synonymous. Water retention is a consequence of excessive weight gain between dialyses. ...
... 26,33 In addition to this, conventional intermittent hemodialysis increases the chances of fluid overload. 13 On the other hand, when hemodialysis is performed daily, it is more similar to the purification of blood obtained by healthy kidneys. Thus, patients on daily hemodialysis experience a significant decrease in interdialytic weight gain, fewer blood pressure problems, and a decrease in episodes of shortness of breath. ...
Objective
to construct a middle range theory for developing the excessive fluid volume risk diagnostic proposition in patients undergoing hemodialysis.
Method
this is a methodological study, developed for the theoretical-causal validity of a nursing diagnosis. The study was carried out in four stages: study selection, identification of the main concepts of the theory, pictogram construction and proposition elaboration. These steps were operationalized through an integrative literature review, with a sample of 82 articles selected from the Web of Science, PubMed, CINAHL, Scopus and Science Direct databases.
Results
the data extracted from the sample articles enabled identifying five essential terms to define excessive fluid volume risk. Furthermore, 31 etiological factors of excessive fluid volume risk were identified, in addition to a pictogram and 12 propositions.
Conclusion and implications for practice
the construction of a middle-range theory focused on excessive fluid volume risk in patients undergoing hemodialysis refines terminology and expands the understanding of nursing phenomena. Thus, the data from this research will provide clear and robust knowledge for the conduct of nurses’ actions in clinical practice.
Keywords:
Adult; Renal Dialysis; Nursing; Body Fluids; Nursing Theory
... 11,12 Nesses pacientes, o volume excessivo de fluidos está associado a um aumento na taxa de hospitalização e alta morbimortalidade. [13][14][15][16] Além disso, sua ocorrência acarreta sérios problemas de saúde nessa clientela, como piora e aumento da prevalência de doenças cardiovasculares, 17,18 além de anormalidades respiratórias restritivas e obstrutivas, como edema agudo de pulmão. 19,20 Portanto, verifica-se que o volume de líquidos excessivo é um importante problema de enfermagem na progressão de resultados clínicos adversos em pacientes em hemodiálise. ...
... Definição: vulnerabilidade à retenção excessiva de líquidos isotônicos que ocorre quando o ganho de peso interdialítico está acima de 3,5% do peso seco, devido à hidratação excessiva, capaz de descontrolar o volume do corpo e comprometer a saúde. 13,16 Embora tenham semelhanças, a retenção hídrica e o ganho de peso interdialítico não são sinônimos. A retenção hídrica é uma consequência do ganho de peso excessivo entre as diálises. ...
... 26,33 Além disso, a hemodiálise convencional intermitente aumenta as chances de sobrecarga hídrica. 13 Em contrapartida, quando a hemodiálise é realizada diariamente, apresenta maior semelhança com a purificação do sangue obtida por rins saudáveis. Assim, os pacientes em hemodiálise diária apresentam uma diminuição significativa no ganho de peso interdialítico, menos problemas de pressão arterial e uma diminuição nos episódios de falta de ar. ...
Objective
to construct a middle range theory for developing the excessive fluid volume risk diagnostic proposition in patients undergoing hemodialysis.
Method
this is a methodological study, developed for the theoretical-causal validity of a nursing diagnosis. The study was carried out in four stages: study selection, identification of the main concepts of the theory, pictogram construction and proposition elaboration. These steps were operationalized through an integrative literature review, with a sample of 82 articles selected from the Web of Science, PubMed, CINAHL, Scopus and Science Direct databases.
Results
the data extracted from the sample articles enabled identifying five essential terms to define excessive fluid volume risk. Furthermore, 31 etiological factors of excessive fluid volume risk were identified, in addition to a pictogram and 12 propositions.
Conclusion and implications for practice
the construction of a middle-range theory focused on excessive fluid volume risk in patients undergoing hemodialysis refines terminology and expands the understanding of nursing phenomena. Thus, the data from this research will provide clear and robust knowledge for the conduct of nurses’ actions in clinical practice.
Keywords:
Adult; Renal Dialysis; Nursing; Body Fluids; Nursing Theory
... It ranks among the most severe of the chronic non-communicable diseases -the survival probability at 1, 3 and 5 years is around 90, 70 and 50%, respectively [2] -and people on dialysis in the UK are admitted to hospital on average around 1.5-2.0 times per year [3]. Quality of life (QoL) is also well below that of the general population [4]. ...
... Based on data from the UKRR [2] and prior linkage of the UKRR to Hospital Episode Statistics [3], we anticipate that at 3 years of follow-up 65% of patients on HD will have experienced our composite endpoint and we plan to detect a hazard ratio (HR) of 0.75. This effect size was agreed to be clinically significant at an investigator meeting involving patients and healthcare professionals. ...
Background
More than a third of the 65,000 people living with kidney failure in the UK attend a dialysis unit 2–5 times a week to have their blood cleaned for 3–5 h. In haemodialysis (HD), toxins are removed by diffusion, which can be enhanced using a high-flux dialyser. This can be augmented with convection, as occurs in haemodiafiltration (HDF), and improved outcomes have been reported in people who are able to achieve high volumes of convection. This study compares the clinical- and cost-effectiveness of high-volume HDF compared with high-flux HD in the treatment of kidney failure.
Methods
This is a UK-based, multi-centre, non-blinded randomised controlled trial. Adult patients already receiving HD or HDF will be randomised 1:1 to high-volume HDF (aiming for 21+ L of substitution fluid adjusted for body surface area) or high-flux HD. Exclusion criteria include lack of capacity to consent, life expectancy less than 3 months, on HD/HDF for less than 4 weeks, planned living kidney donor transplant or home dialysis scheduled within 3 months, prior intolerance of HDF and not suitable for high-volume HDF for other clinical reasons. The primary outcome is a composite of non-cancer mortality or hospital admission with a cardiovascular event or infection during follow-up (minimum 32 months, maximum 91 months) determined from routine data. Secondary outcomes include all-cause mortality, cardiovascular- and infection-related morbidity and mortality, health-related quality of life, cost-effectiveness and environmental impact. Baseline data will be collected by research personnel on-site. Follow-up data will be collected by linkage to routine healthcare databases — Hospital Episode Statistics, Civil Registration, Public Health England and the UK Renal Registry (UKRR) in England, and equivalent databases in Scotland and Wales, as necessary — and centrally administered patient-completed questionnaires. In addition, research personnel on-site will monitor for adverse events and collect data on adherence to the protocol (monthly during recruitment and quarterly during follow-up).
Discussion
This study will provide evidence of the effectiveness and cost-effectiveness of HD as compared to HDF for adults with kidney failure in-centre HD or HDF. It will inform management for this patient group in the UK and internationally.
Trial registration
ISRCTN10997319. Registered on 10 October 2017
... It ranks among the most severe of the chronic non-communicable diseases -the survival probability at one, three and ve years is around 90, 70 and 50%, respectively (3) and people on dialysis in the UK are admitted to hospital on average around 1.5-2.0 times per year (4). Quality of life (QoL) is also well below that of the general population (5). ...
Background
More than a third of the 65,000 people living with kidney failure in the UK attend a dialysis unit 2–5 times a week to have their blood cleaned for 3–5 hours. In haemodialysis (HD) toxins are removed by diffusion, which can be enhanced using a high-flux dialyser. This can be augmented with convection, as occurs in haemodiafiltration (HDF) and improved outcomes have been reported in people who are able to achieve high volumes of convection. This study compares the clinical- and cost-effectiveness of high-volume HDF compared with high-flux HD in the treatment of kidney failure.
Methods
This is a UK-based, multi-centre, non-blinded randomised controlled trial. Adult patients already receiving HD or HDF will be randomised 1:1 to high-volume HDF (aiming for 21 + L of substitution fluid adjusted for body surface area) or high-flux HD. Exclusion criteria include lack of capacity to consent, life expectancy less than 3 months, on HD/HDF for less than 4 weeks, planned living kidney donor transplant or home dialysis scheduled within 3 months, prior intolerance of HDF, and not suitable for high-volume HDF for other clinical reasons. The primary outcome is a composite of non-cancer mortality or hospital admission with a cardiovascular event or infection during follow-up (minimum 32 months, maximum 91 months) determined from routine data. Secondary outcomes include all-cause mortality, cardiovascular and infection related morbidity and mortality, health-related quality of life, cost-effectiveness and environmental impact. Baseline data will be collected by research personnel on-site. Follow up data will be collected by linkage to routine healthcare databases – Hospital Episode Statistics, Civil Registration, Public Health England, and the UK Renal Registry (UKRR) in England, and equivalent databases in Scotland and Wales, as necessary – and centrally administered patient completed questionnaires. In addition, research personnel on-site will monitor for adverse events and collect data on adherence to the protocol (monthly during recruitment and quarterly during follow-up).
Discussion
This study will provide evidence of the effectiveness and cost effectiveness of HD as compared to HDF for adults with kidney failure in-centre HD or HDF. It will inform management for this patient group in the UK and internationally.
Trial registration
ISRCTN10997319. Registered on 10th October 2017.
... 15 Similar findings have been shown in a cohort of patients from the United Kingdom Renal Registry, with a 70% increase in hospital admission rates following the 2-day gap, and a 20% increase in mortality. 29 Additionally, a registry study of dialysis patients from a Canadian cohort demonstrated a 34% increase in emergency department visits on Monday and a 20% increase on Tuesday versus other days of the week among patients on a Monday-Wednesday-Friday schedule. 30 In particular, it has been suggested that there may be a benefit in reducing cardiovascular-related hospital admissions when comparing patients receiving more frequent home hemodialysis versus those on 3Â-weekly schedules. ...
Introduction
New personal hemodialysis systems, such as the quanta SC+, are being developed; these systems are smaller and simpler to use while providing the clearances of conventional systems. Increasing the uptake of lower‐intensity assistance and full self‐care dialysis may provide economic benefits to the public health payer. In the United Kingdom, most hemodialysis patients currently receive facility‐based dialysis costing more than £36,350 per year including patient transport. As such, we aimed to describe the annual costs of using the SC+ hemodialysis system in the United Kingdom for 3×‐weekly and 3.5×‐weekly dialysis regimens, for self‐care hemodialysis provided both in‐center and at home.
Methods
We applied a cost minimization approach. Costs for human resources, equipment, and consumables were sourced from the dialysis machine developer (Quanta Dialysis Technologies) based upon discussions with dialysis providers. Facility overhead expenses and transport costs were taken from a review of the literature.
Findings
Annual costs associated with the use of the SC+ hemodialysis system were estimated to be £26,642 for hemodialysis provided 3× weekly as home self‐care; £30,235 for hemodialysis provided 3× weekly as self‐care in‐center; £29,866 for hemodialysis provided 3.5× weekly as home self‐care; and £36,185 for hemodialysis provided 3.5× weekly as self‐care in‐center.
Discussion
We found that the SC+ hemodialysis system offers improved cost‐effectiveness for both 3×‐weekly and 3.5×‐weekly self‐care dialysis performed at home or as self‐care in‐center versus fully assisted dialysis provided 3× weekly with conventional machines in facilities.
... Similarly, 12% HD sessions were missed over one-year 17 period in another study conducted by Khattak et al . There is some evidence to believe that mortality and hospital admissions are higher during the long 18 interdialytic period of the week . However, in this study, we did not correlate the outcomes specifically with particular days of the week. ...
Objective: To determine the effect of missed haemodialysis sessions. Methods: This cohort study was carried out from July to October 2019. Patients on maintenance haemodialysis were selected by consecutive sampling technique. Exclusion criteria included patients admitted to hospital during first month of study, haemodialysis for acute kidney injury, haemodialysis from multiple dialysis units, haemodialysis less than two times a week and unwilling patients. Data on haemodialysis sessions carried out during July 2019 was recorded to document attendance patterns. Patients were followed up for all-cause mortality, hospital admissions and need for haemodialysis in emergency over next three months. Results: Appointments were given to 84 patients, aged 59.27± 14.09 years, for 700 sessions during July. Amongst them, 24 (28.57%) missed 34 (4.86%) haemodialysis sessions. At least one haemodialysis session was missed by 14 (26.92%) males as compared to 10 (31.25%) females (p=0.670). During follow up period, 12 (14.29%) patients died. Five of 24 patients missing dialysis died, as compared to seven out of 60 patients with good compliance (p=0.310; relative risk: 1.992). Eight out of 24 patients missing dialysis required hospital admissions, as compared to 19 out of 60 patients with good compliance (p=0.883; relative risk: 1.079). Seven out of 24 patients missing dialysis required emergency haemodialysis, as compared to 12 out of 60 patients with good compliance (p=0.364; relative risk: 1.647). Conclusion: There was a statistically insignificant greater trend towards mortality and need for emergency haemodialysis amongst poorly compliant patients.
... ultrafiltration volume, dialysate sodium concentration) in conventional thrice-weekly HD might induce excessive hemodynamic stress and potential organ damage, with potentially deleterious consequences on long-term outcomes. Interestingly, it is widely recognized that a long interdialytic gap in a thrice-weekly treatment schedule is associated with a significant increase in hospitalization and mortality from CV origins [88][89][90]. From a clinical perspective, it is well perceived that assessment and management of the fluid status of HD patients is not an easy task. Whatever the complexity, that should remain the basic fundamental and permanent aim in HD patient management, to control blood pressure and to restore hemodynamic equilibrium. ...
Hemodialysis (HD) is a life-sustaining therapy as well as an intermittent and repetitive stress condition for the patient. In ridding the blood of unwanted substances and excess fluid from the blood, the extracorporeal procedure simultaneously induces persistent physiological changes that adversely affect several organs. Dialysis patients experience this systemic stress condition usually thrice weekly and sometimes more frequently depending on the treatment schedule. Dialysis-induced systemic stress results from multifactorial components that include treatment schedule (i.e. modality, treatment time), hemodynamic management (i.e. ultrafiltration, weight loss), intensity of solute fluxes, osmotic and electrolytic shifts and interaction of blood with components of the extracorporeal circuit. Intradialytic morbidity (i.e. hypovolemia, intradialytic hypotension, hypoxia) is the clinical expression of this systemic stress that may act as a disease modifier, resulting in multiorgan injury and long-term morbidity. Thus, while lifesaving, HD exposes the patient to several systemic stressors, both hemodynamic and non-hemodynamic in origin. In addition, a combination of cardiocirculatory stress, greatly conditioned by the switch from hypervolemia to hypovolemia, hypoxemia and electrolyte changes may create pro-arrhythmogenic conditions. Moreover, contact of blood with components of the extracorporeal circuit directly activate circulating cells (i.e. macrophages-monocytes or platelets) and protein systems (i.e. coagulation, complement, contact phase kallikrein-kinin system), leading to induction of pro-inflammatory cytokines and resulting in chronic low-grade inflammation, further contributing to poor outcomes. The multifactorial, repetitive HD-induced stress that globally reduces tissue perfusion and oxygenation could have deleterious long-term consequences on the functionality of vital organs such as heart, brain, liver and kidney. In this article, we summarize the multisystemic pathophysiological consequences of the main circulatory stress factors. Strategies to mitigate their effects to provide more cardioprotective and personalized dialytic therapies are proposed to reduce the systemic burden of HD.
