Table 1 - uploaded by Zbylut J Twardowski
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Chronic hemodialysis sessions, as developed in Seattle in the 1960s, were long procedures with minimal intra- and interdialytic symptoms. Over the next three decades, dialysis duration was shorten to 4, 3, even 2 h in thrice weekly schedules. This method spread rapidly, particularly in the United States, after the National Cooperative Dialysis Stud...
Citations
... To improve the blood pressure, the patient is offered an intervention such as a bolus of saline or slowing of the ultrafiltration rate and/or placing the patient in the Trendelenburg position. IDH can result in cramping, dizziness, vomiting, fainting, and fatigue, with highly unstable sessions potentially leading to hospitalization or death [4][5][6]. Although IDH presents serious risks to patients undergoing hemodialysis, modifying patient behavior may prevent its occurrence. ...
Background
Patients on hemodialysis receive dialysis thrice weekly for about 4 hours per session. Intradialytic hypotension (IDH)—low blood pressure during hemodialysis—is a serious but common complication of hemodialysis. Although patients on dialysis already participate in their care, activating patients toward IDH prevention may reduce their risk of IDH. Interactive, technology-based interventions hold promise as a platform for patient activation. However, little is known about the usability challenges that patients undergoing hemodialysis may face when using tablet-based informatics interventions, especially while dialyzing.
Objective
This study aims to test the usability of a patient-facing, tablet-based intervention that includes theory-informed educational modules and motivational interviewing–based mentoring from patient peers via videoconferencing.
Methods
We conducted a cross-sectional, mixed methods usability evaluation of the tablet-based intervention by using think-aloud methods, field notes, and structured observations. These qualitative data were evaluated by trained researchers using a structured data collection instrument to capture objective observational data. We calculated descriptive statistics for the quantitative data and conducted inductive content analysis using the qualitative data.
Results
Findings from 14 patients cluster around general constraints such as the use of one arm, dexterity issues, impaired vision, and lack of experience with touch screen devices. Our task-by-task usability results showed that specific sections with the greatest difficulty for users were logging into the intervention (difficulty score: 2.08), interacting with the quizzes (difficulty score: 1.92), goal setting (difficulty score: 2.28), and entering and exiting videoconference rooms (difficulty score: 2.07) that are used to engage with peers during motivational interviewing sessions.
Conclusions
In this paper, we present implications for designing informatics interventions for patients on dialysis and detail resulting changes to be implemented in the next version of this intervention. We frame these implications first through the context of the role the patients’ physical body plays when interacting with the intervention and then through the digital considerations for software and interface interaction.
... In this regard, the "efficiency goal", stating that kinetic adequacy is the essential requisite for "good dialysis", is pertinent to younger patients, but is progressively replaced by a "tolerance goal" in the elderly, where "good dialysis" should have minimal side effects [34][35][36]. ...
There is no simple way to prescribe hemodialysis. Changes in the dialysis population, improvements in dialysis techniques, and different attitudes towards the initiation of dialysis have influenced treatment goals and, consequently, dialysis prescription. However, in clinical practice prescription of dialysis still often follows a “one size fits all” rule, and there is no agreed distinction between treatment goals for the younger, lower-risk population, and for older, high comorbidity patients. In the younger dialysis population, efficiency is our main goal, as assessed by the demonstrated close relationship between depuration (tested by kinetic adequacy) and survival. In the ageing dialysis population, tolerance is probably a better objective: “good dialysis” should allow the patient to attain a stable metabolic balance with minimal dialysis-related morbidity. We would like therefore to open the discussion on a personalized approach to dialysis prescription, focused on efficiency in younger patients and on tolerance in older ones, based on life expectancy, comorbidity, residual kidney function, and nutritional status, with particular attention placed on elderly, high-comorbidity populations, such as the ones presently treated in most European centers. Prescription of dialysis includes reaching decisions on the following elements: dialysis modality (hemodialysis (HD) or hemodiafiltration (HDF)); type of membrane (permeability, surface); and the frequency and duration of sessions. Blood and dialysate flow, anticoagulation, and reinfusion (in HDF) are also briefly discussed. The approach described in this concept paper was developed considering the following items: nutritional markers and integrated scores (albumin, pre-albumin, cholesterol; body size, Body Mass Index (BMI), Malnutrition Inflammation Score (MIS), and Subjective Global Assessment (SGA)); life expectancy (age, comorbidity (Charlson Index), and dialysis vintage); kinetic goals (Kt/V, normalized protein catabolic rate (n-PCR), calcium phosphate, parathyroid hormone (PTH), beta-2 microglobulin); technical aspects including vascular access (fistula versus catheter, degree of functionality); residual kidney function and weight gain; and dialysis tolerance (intradialytic hypotension, post-dialysis fatigue, and subjective evaluation of the effect of dialysis on quality of life). In the era of personalized medicine, we hope the approach described in this concept paper, which requires validation but has the merit of providing innovation, may be a first step towards raising attention on this issue and will be of help in guiding dialysis choices that exploit the extraordinary potential of the present dialysis “menu”.
... The amount of fluid to be removed can for instance be reduced by tailored nursing interventions focusing on adherence behaviour (Lindberg et al., 2011; Welch and Thomas-Hawkins, 2005). Further, by using a patient-centred nursing care approach (Doss et al., 2011) and/or nurse–patient negotiation (Polaschek, 2003), the dialysis session time and thus the time of ultrafiltration can be extended beyond the necessary time for waste clearance and thus provide a better tolerance of ultrafiltration (Twardowski, 2007). A quality indicator has more or less two main functions: to indicate need for change and to evaluate change results. ...
... A patient-centred care approach (Doss et al., 2011) necessitates that the treatment is adjusted to the needs of each patient and the ultrafiltration rate indicator will thus reflect the nursing in each treatment session. Another disadvantage is the likelihood that the longer dialysis session required for decreasing the ultrafiltration rate (Twardowski, 2007) might be impossible due to the department's capacity. Maybe the patient does not agree to extend the session. ...
Nursing quality indicators are widely used to demonstrate nurses' contributions to health care. Some studies in nephrology settings have addressed nursing quality, but indicators reflecting the nursing process quality in haemodialysis are lacking. This paper argues for considering ultrafiltration rate as a nursing-sensitive quality indicator in haemodialysis. Strategies and qualifications for considering ultrafiltration rate as a nursing quality indicator are established and discussed. It is argued that the indicator is associated with nursing practice, linked to both morbidity and mortality, and is within the scope of the nurse's responsibility. It is also argued that the indicator could be influenced by other factors than nursing care. Thus, further studies are needed to investigate the association between ultrafiltration rate and patient safety. The introduction of the ultrafiltration rate as a duty specific quality indicator is a coveted measure of nursing care quality in haemodialysis settings.
... Although this reduced time on dialysis seems to be an advantage to the patient, the drawback is that less time is available for UF. 1 The ensuing increase in ultrafiltration rate (Q UF ) enlarges the imbalance between refill and UF and thus increases the propensity to hypotension. In this respect, methods that increase refill from the interstitial space would be of great value. ...
Methods to continuously measure absolute refill during dialysis are not available. It would be useful to have such a method because it would allow investigating the mechanism of refill the effect of interventions. We designed a feedback algorithm that adjusts ultrafiltration rate (QUF) according to hemoglobin (Hb) concentration changes in such a way that relative blood volume (BV) remains constant within a narrow target range. In this situation, the generated QUF quantitatively reflects refill. Refill patterns were studied in five hypotension prone patients. In addition, on separate occasions, we studied the effect of antiembolism stockings (AES) and infusion of hydroxy-ethylated starch (HAES) on refill in these patients. Refill during the first hour fell significantly from 21 +/- 3 ml/min to 9 +/- 2 ml/min (p < 0.05). In the second hour, refill decreased further and became zero in four out of five patients. Neither AES nor HAES measurably affected refill. The marked and rapid fall in refill in the early stages of dialysis suggests untimely depletion of the interstitial compartment and underestimation of dry weight. We propose that continuous, online measurement of refill patterns may be of value for accurate estimation of dry weight in dialysis patients.
Background:
End-stage kidney disease (ESKD) is treated with dialysis or kidney transplantation, with most patients with ESKD receiving in-center hemodialysis treatment. This life-saving treatment can result in cardiovascular and hemodynamic instability, with the most common form being low blood pressure during the dialysis treatment (intradialytic hypotension [IDH]). IDH is a complication of hemodialysis that can involve symptoms such as fatigue, nausea, cramping, and loss of consciousness. IDH increases risks of cardiovascular disease and ultimately hospitalizations and mortality. Provider-level and patient-level decisions influence the occurrence of IDH; thus, IDH may be preventable in routine hemodialysis care.
Objective:
This study aims to evaluate the independent and comparative effectiveness of 2 interventions-one directed at hemodialysis providers and another for patients-in reducing the rate of IDH at hemodialysis facilities. In addition, the study will assess the effects of interventions on secondary patient-centered clinical outcomes and examine factors associated with a successful implementation of the interventions.
Methods:
This study is a pragmatic, cluster randomized trial to be conducted in 20 hemodialysis facilities in the United States. Hemodialysis facilities will be randomized using a 2 × 2 factorial design, such that 5 sites will receive a multimodal provider education intervention, 5 sites will receive a patient activation intervention, 5 sites will receive both interventions, and 5 sites will receive none of the 2 interventions. The multimodal provider education intervention involved theory-informed team training and the use of a digital, tablet-based checklist to heighten attention to patient clinical factors associated with increased IDH risk. The patient activation intervention involves tablet-based, theory-informed patient education and peer mentoring. Patient outcomes will be monitored during a 12-week baseline period, followed by a 24-week intervention period and a 12-week postintervention follow-up period. The primary outcome of the study is the proportion of treatments with IDH, which will be aggregated at the facility level. Secondary outcomes include patient symptoms, fluid adherence, hemodialysis adherence, quality of life, hospitalizations, and mortality.
Results:
This study is funded by the Patient-Centered Outcomes Research Institute and approved by the University of Michigan Medical School's institutional review board. The study began enrolling patients in January 2023. Initial feasibility data will be available in May 2023. Data collection will conclude in November 2024.
Conclusions:
The effects of provider and patient education on reducing the proportion of sessions with IDH and improving other patient-centered clinical outcomes will be evaluated, and the findings will be used to inform further improvements in patient care. Improving the stability of hemodialysis sessions is a critical concern for clinicians and patients with ESKD; the interventions targeted to providers and patients are predicted to lead to improvements in patient health and quality of life.
Trial registration:
ClinicalTrials.gov NCT03171545; https://clinicaltrials.gov/ct2/show/NCT03171545.
International registered report identifier (irrid):
PRR1-10.2196/46187.
Background
Rapid fluid removal during hemodialysis has been associated with increased mortality. The limit of ultrafiltration rate (UFR) monitored by the Centers for Medicare & Medicaid Services is 13 ml/kg per hour. It is not clear if the proportion of treatments with high UFR is associated with higher mortality. We examined the association of proportion of dialysis treatments with high UFR and mortality in end stage kidney failure patients receiving hemodialysis.
Methods
This was a retrospective study of incident patients initiating hemodialysis between January 1, 2010, and December 31, 2019, at Emory dialysis centers. The proportion of treatments with high UFR (>13 ml/kg per hour) per patient was calculated using data from the initial 3 months of dialysis therapy. Patients were categorized on the basis of quartiles of proportion of dialysis sessions with high UFR. Risk of death and survival probabilities were calculated and compared for all quartiles.
Results
Of 1050 patients eligible, the median age was 59 years, 56% were men, and 91% were Black. The median UFR was 6.5 ml/kg per hour, and the proportion of sessions with high UFR was 5%. Thirty-one percent of patients never experienced high UFR. Being a man, younger age, shorter duration of hemodialysis sessions, lower weight, diabetic status, higher albumin, and history of heart failure were associated with a higher proportion of sessions with high UFR. Patients in the higher quartile (26% dialysis with high UFR, average UFR 9.8 ml/kg per hour, median survival of 5.6 years) had a higher risk of death (adjusted hazard ratio 1.54; 95% CI, 1.13 to 2.10) compared with those in the lower quartile (0% dialysis with high UFR, average UFR 4.7 ml/kg per hour, median survival 8.8 years).
Conclusions
Patients on hemodialysis who did not experience frequent episodes of elevated UFR during the first 3 months of their dialysis tenure had a significantly lower risk of death compared with patients with frequent episodes of high UFR.
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.
The extent of removal of the uremic toxins in hemodialysis (HD) therapies depends primarily on the dialysis membrane characteristics and the solute transport mechanisms involved. While designation of 'flux' of membranes as well toxicity of compounds that need to be targeted for removal remain unresolved issues, the relative role, efficiency and utilization of solute removal principles to optimize HD treatment are better delineated. Through the combination and intensity of diffusive and convective removal forces, levels of concentrations of a broad spectrum of uremic toxins can be lowered significantly and successfully. Extended clinical experience as well as data from several clinical trials attest to the benefits of convection-based HD treatment modalities. However, the mode of delivery of HD can further enhance the effectiveness of therapies. Other than treatment time, frequency and location that offer clinical benefits and increase patient well-being, treatment-and patient-specific criteria may be tailored for the therapy delivered: electrolytic composition, dialysate buffer and concentration and choice of anticoagulating agent are crucial for dialysis tolerance and efficacy. Evidence-based medicine (EBM) relies on three tenets, i.e. clinical expertise (i.e. doctor), patient-centered values (i.e. patient) and relevant scientific evidence (i.e. science), that have deviated from their initial aim and summarized to scientific evidence, leading to tyranny of randomized controlled trials. One must recognize that practice patterns as shown by Dialysis Outcomes and Practice Patterns Study and personalization of HD care are the main driving force for improving outcomes. Based on a combination of the three pillars of EBM, and particularly on bedside patient-clinician interaction, we summarize what we have learned over the last 6 decades in terms of best practices to improve outcomes in HD patients. Management of initiation of dialysis, vascular access, preservation of kidney function, selection of biocompatible dialysers and use of dialysis fluids of high microbiological purity to restrict inflammation are just some of the approaches where clinical experience is vital in the absence of definitive scientific evidence. Further, HD adequacy needs to be considered as a broad and multitarget approach covering not just the dose of dialysis provided, but meeting individual patient needs (e.g. fluid volume, acid-base, blood pressure, bone disease metabolism control) through regular assessment-and adjustment-of a series of indicators of treatment efficiency. Finally, in whichever way new
Objective:
To identify the factors related to post-hemodialysis recovery time in kidney failure patients.
Method:
This study used a descriptive correlation design with a cross-sectional method. The samples in the study were 185 hemodialysis patients at Sanglah Central Hospital, Denpasar, who were recruited through a consecutive sampling technique. Data were analyzed using multiple linear regressions.
Results:
The results of the study showed that the mean recovery time was 578.41±402.27min. Post-hemodialysis recovery time was found to be significantly related to the hemodialysis schedule (p=0.029), comorbid diseases (p=0.046), the number of acute complications (p=0.001), and depression (p=0.004). The results of multivariate analysis showed that the number of acute complications during hemodialysis was the most dominant factor related to recovery time (β=0.747).
Conclusion:
Gender, upper-arm circumference, hemodialysis schedule, sodium dialysate concentration, intradialytic weight loss, comorbid diseases, and the number of acute complications were found to be significant correlated with post-hemodialysis recovery time.
Background
End‐stage kidney disease (ESKD) patients have increased mortality compared to the general population. Haemodialysis (HD) of more frequent and of longer duration has been proposed to improve survival but it remains unclear if this is attributed to increased frequency, duration, or both. We aimed to examine the independent effects of session frequency and duration on mortality in incident HD patients.
Methods
A retrospective cohort study was performed using data from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA) examining non‐Indigenous patients aged ≥18 years who initiated HD of ≥3 sessions/week in Australia from 2001‐2015. Initial dialysis prescription was categorised as session duration >5 hours/session compared to ≤5 hours/session and session frequency as >3 sessions/week compared to 3 sessions/week. Survival analysis was performed using Cox regression analysis, with multivariable analysis controlling for available covariates.
Results
We examined 16,944 patients of whom 757 (4.5%) received >3 sessions/week and 518 (3.1%) received >5 hours/session. After controlling for frequency, patients initiated on HD sessions >5 hours had a significantly reduced risk of mortality compared with patients with HD session ≤5 hours (adjusted HR=0.57; 95% CI 0.44‐0.74). In contrast, patients initiated on >3 sessions/week of HD had a similar risk of death when compared with patients on 3 sessions/week of HD (adjusted HR=0.97; 95% CI 0.84‐1.13), after controlling for duration. Limitations include potential residual confounding and changes in exposure over time.
Conclusion
Longer duration rather than increased frequency of treatment appears to reduce mortality in HD patients. This has implications for management and requires further study.
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