[Show abstract][Hide abstract] ABSTRACT: Abstract
BACKGROUND AND OBJECTIVES:
In-center hemodialysis (HD) is often the default dialysis modality for older patients. Few centers use assisted peritoneal dialysis (PD), which enables treatment at home. This observational study compared quality of life (QoL) and physical function between older patients on assisted PD and HD.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:
Patients on assisted PD who were >60 years old and on dialysis for >3 months were recruited and matched to patients on HD (needing hospital transport) by age, sex, diabetes, dialysis vintage, ethnicity, and index of deprivation. Frailty was assessed using the Clinical Frailty Scale. QoL assessments included Hospital Anxiety and Depression Scale (HADS), Short Form-12, Palliative Outcomes Symptom Scale (renal), Illness Intrusiveness Rating Scale, and Renal Treatment Satisfaction Questionnaire (RTSQ). Physical function was evaluated by Barthel Score and timed up and go test.
In total, 251 patients (129 PD and 122 HD) were recruited. In unadjusted analysis, patients on assisted PD had a higher prevalence of possible depression (HADS>8; PD=38.8%; HD=23.8%; P=0.05) and higher HADS depression score (median: PD=6; HD=5; P=0.05) but higher RTSQ scores (median: PD=55; HD=51; P<0.01). In a generalized linear regression model adjusting for age, sex, comorbidity, dialysis vintage, and frailty, assisted PD continued to be associated with higher RTSQ scores (P=0.04) but not with other QoL measures.
There are no differences in measures of QoL and physical function between older patients on assisted PD and comparable patients on HD, except for treatment satisfaction, which is higher in patients on PD. Assisted PD should be considered as an alternative to HD for older patients, allowing them to make their preferred choices.
Preview · Article · Dec 2015 · Clinical Journal of the American Society of Nephrology
[Show abstract][Hide abstract] ABSTRACT: The number of elderly patients on maintenance dialysis has rapidly increased in the past few decades, particularly in developed
countries, imposing a growing burden on dialysis centres. Hence, many nephrologists and healthcare authorities feel that greater
emphasis should be placed on the promotion of home dialysis therapies such as peritoneal dialysis (PD) and home haemodialysis
(HD). There is currently no general consensus as to the best dialysis modality for elderly patients with end-stage renal disease.
In-centre HD is predominant in most countries, although it is widely recognized that PD has several advantages over HD, including
the lack of need for vascular access, continuous slow ultrafiltration, less interference with patients' lifestyle and lower
costs. Comparisons of outcomes between elderly patients on PD and HD rely on observational studies, as randomized controlled
trials are lacking. The results of these studies are variable. However, most of them suggest that survival rates are largely
similar between the two modalities, except for elderly patients with diabetes and/or beyond 1–3 years from dialysis initiation,
in which cases HD appears to be superior. An equally important aspect to consider when choosing dialysis modality, particularly
in this age group, is the quality of life, and in this regard most studies found no significant differences between PD and
HD. In these circumstances, we believe that dialysis modality selection should be guided by patient's preference, based on
comprehensive and unbiased information. A multidisciplinary team should review elderly patients starting on dialysis, aiming
to identify possible barriers to PD and home HD, including physical, visual, cognitive, psychological and social problems,
and to overcome such barriers by adequate care, education, psychological counselling and dialysis assistance.
Full-text · Article · Dec 2015 · Nephrology Dialysis Transplantation
[Show abstract][Hide abstract] ABSTRACT: Background
There is a variation in dialysis withdrawal rates, but reasons for this variation across European countries are largely unknown. We therefore surveyed nephrologists' perceptions of factors concerning dialysis withdrawal and palliative care and explored relationships between these perceptions and reports of whether withdrawal actually occurred in practice.
We developed a 33-item electronic survey, disseminated via an email blast to all European Renal Association–European Dialysis and Transplant Association (ERA-EDTA) members. In our data analyses, we distinguished those respondents who reported occurrence from those reporting no dialysis withdrawal in their unit. With multilevel logistic regression, we investigated the association between respondents' characteristics and perceptions and whether they reported occurrence of dialysis withdrawal or not.
Five hundred and twenty-eight nephrologists from 45 countries completed the questionnaire; 42% reported occurrence of withdrawal in their unit in the past year, and 56% perceived that stopping life-prolonging treatment in terminally ill patients was allowed. Few respondents reported presence in their unit of protocols on withdrawal decision making (7%) or palliative care (10%) or the common involvement of a geriatrician in withdrawal decisions (10%). The majority stated that palliative care had not been part of their core curriculum (74%) and that they had not recently attended continuous medical education sessions on this topic (73%). Respondents from Eastern and Southern Europe had a 42 and 40% lower probability, respectively, of reporting withdrawal compared with those from North European countries. Working in a public centre [odds ratio (OR), 2.41; 95% confidence interval (CI), 1.36–4.25] and respondents' perception that stopping life-prolonging treatment in terminally ill patients was allowed (OR, 1.96; 95% CI, 1.23–3.12), that withdrawal decisions were commonly shared between doctor and patient (OR, 1.97; 95% CI, 1.26–3.08) and that palliative care was reimbursed (OR, 1.81; 95% CI, 1.16–2.83) increased the odds of reporting occurrence of withdrawal.
Reports of dialysis withdrawal occurrence varied between European countries. Occurrence reports were more likely if respondents worked in a public centre, if stopping life-prolonging treatments was perceived as allowed, if withdrawal decisions were considered shared between doctors and patients and if reimbursement of palliative care was believed to be in place. There is room for improvement regarding protocols on withdrawal and palliative care processes and regarding nephrologists' training and education on end-of-life care.
Full-text · Article · Aug 2015 · Nephrology Dialysis Transplantation
[Show abstract][Hide abstract] ABSTRACT: Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.
[Show abstract][Hide abstract] ABSTRACT: Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines.Kidney International advance online publication, 29 April 2015; doi:10.1038/ki.2015.110.
Full-text · Article · Apr 2015 · Kidney International
[Show abstract][Hide abstract] ABSTRACT: South Asian people have a higher risk of developing kidney disease, are disproportionately represented in the patient population requiring renal replacement therapy and wait longer to receive a kidney transplant, compared with white Europeans. As a result, there is a demand for end-of-life care, which meets the needs of this group of patients. Providing end-of-life care to patients from different cultures is a challenge for renal services as there can be barriers to communication in the form of language, delegated decision-making within families and reluctance to discuss death. To explore end-of-life care for South Asians with kidney disease, 16 interviews with patients and 14 focus groups with care providers were conducted at four research sites in the UK with large South Asian populations. Using an action research design the data were analysed thematically and fed back to inform the research in a cyclical manner. If patients are not fully aware of their condition or of what end-of-life care is, it is less likely that they will be able to be involved in decision-making about their care and this is compounded where there are communication barriers. Variations in care provider awareness and experience of providing end-of-life care to South Asian patients, in turn, contributes to lack of patient awareness of end-of-life care. Communication as care at the end of life should be explored further. Researching the South Asian patient experience of end of life highlights many relevant and generalisable issues.
Full-text · Article · Sep 2014 · Journal of Renal Care
[Show abstract][Hide abstract] ABSTRACT: The incidence of older patients with end stage renal disease is on the increase. This group of patients have multiple comorbidities and a high symptom burden. Dialysis can be life sustaining for such patients. But it is often at the expense of quality of life, which starts to decline early in the pathway of chronic kidney disease. Quality of life is also important to patients and is a major determinant in decisions regarding renal replacement. As a result, validated patient-reported outcome measures are increasingly used to assess quality of life in renal patients. Cognitive impairment, depression, malnutrition and function decline are non-renal determinants of quality of life and mortality. They are under-recognised in the renal population but are potentially treatable, if not preventable. This review article discusses aetio-pathogenesis, prevalence and impact of these four outcomes, advocating regular screening for early identification and management.
No preview · Article · Mar 2014 · Postgraduate medical journal
[Show abstract][Hide abstract] ABSTRACT: Background:
Encapsulating peritoneal sclerosis (EPS) is a rare but devastating complication of long-term peritoneal dialysis (PD). There is no well-validated method for predicting which patients will develop the condition, although known risk factors include long duration of PD, high glucose exposure and lack of residual renal function. We have investigated whether dialysate cytokines (MCP-1 (monocyte chemotactic protein-1), CCL18 (pulmonary and activation-regulated cytokine, PARC), IL-6 (interleukin-6), CCL15 (leukotactin) and angiogenin) could be used to predict the onset of EPS more effectively than known clinical risk factors.
Samples of dialysate and clinical data were prospectively collected from 151 patients at the West London Renal center between 2003 and 2010. Dialysate cytokine levels were measured using the enzyme-linked immunoabsorbant assay (ELISA) technique. Encapsulating peritoneal sclerosis subsequently developed in 17 patients during a follow-up period of 27 - 113 months. Cytokines found at higher levels in dialysate of pre-EPS patients were investigated as candidate predictors of EPS using logistic regression analysis.
Dialysate IL-6, MCP-1 and CCL15 were significantly higher in patients who subsequently developed EPS; however, a logistic regression model using dialysate cytokines to predict EPS was no better than a model using well-recognized clinical markers (length of time on PD and membrane transport status).
Although MCP-1, IL-6 and CCL15 were found at higher levels in the dialysate of patients who subsequently developed EPS, dialysate levels of these cytokines do not improve prediction of future EPS above a model using known clinical risk factors.
[Show abstract][Hide abstract] ABSTRACT: Background/aims:
Cognitive impairment is a common but under-recognised problem in patients with chronic kidney disease, and is likely to become more significant as this patient population ages.
This cross-sectional study focussed on inpatients aged ≥65 years at a tertiary renal unit, and consisted of two parts. Part 1 (n = 25) considered whether cognitively impaired inpatients were being identified and being referred to memory services. In Part 2 (n = 105) two different cognitive function tests were attempted (6-CIT, MMSE).
In Part 1, cognitive function tests were attempted in only 4 patients at admission and 1 patient subsequently. No patients were referred to memory services. In Part 2, 6-CIT was abnormal (score ≥8) in 61.4%, and MMSE was abnormal (score <27) in 79.5% (score 21-26: 28.9%, 15-20: 28.9%, 10-14: 13.3%, <10: 8.4%). There was a close correlation between MMSE and 6-CIT (R(2) = 0.735). Only 7.2% of those assessed had a documented cognitive deficit prior to admission.
This is the first study looking at cognition in elderly inpatients with chronic kidney disease. There appears to be a much higher rate of cognitive impairment than expected and this is largely unidentified. These deficits are likely to have a major impact on both inpatient and outpatient management.
No preview · Article · Jan 2014 · Nephron Clinical Practice
[Show abstract][Hide abstract] ABSTRACT: Encapsulating peritoneal sclerosis (EPS), a rare but serious complication of long-term PD, is characterized by nausea, abdominal pain, weight loss, anorexia, and constipation. It can cause a significant deterioration in a patient's nutrition status. In the present study we examined changes in nutrition status and outcomes for patients with EPS treated conservatively without the use of surgical intervention.
Patients diagnosed with EPS at our institution between December 2006 and December 2010 were identified, and data on demographics, nutrition, and symptoms were collected every 2 months for 12 months and then at 18 and 24 months.
Of the 15 patients identified, 12 were malnourished or at risk of malnutrition according to their subjective global assessment score, with 11 of the 15 presenting with more than 10% weight loss in the 6 months before diagnosis. Furthermore, symptom burden was high, with 11 of 15 patients reporting 2 or more gastrointestinal symptoms. Of the 15 patients, 12 required parenteral nutrition for a median of 4.5 months, and 5 died within the first 12 months after diagnosis. In the 10 survivors, albumin and C-reactive protein significantly improved over the 24 months after diagnosis. Improving trends in weight and symptoms were also observed in those patients.
In some patients with EPS, a conservative approach without surgical intervention, and with regular dietetic input and aggressive nutrition support, can lead to improved nutrition status and symptoms.
[Show abstract][Hide abstract] ABSTRACT: Increasing numbers of frail elderly with end-stage renal disease (ESRD) and multiple comorbidities are undertaking dialysis treatment. This has been accompanied by increasing dialysis withdrawal, thus warranting investigation into why this is occurring and whether a different approach to choosing treatment should be implemented. Despite being a potentially life-saving treatment, the physical and psychosocial burdens associated with dialysis in the frail elderly usually outweigh the benefits of correcting uraemia. Conservative management is less invasive and avoids the adverse effects associated with dialysis, but unfortunately it is often not properly considered until patients withdraw from dialysis. Shared decision-making has been proposed to allow patients active participation in healthcare decisions. Through this approach, patients will focus on their personal values to receive appropriate treatment, and perhaps opt for conservative management. This may help address the issue of dialysis withdrawal. Moreover, shared decision-making attempts to resolve the conflict between autonomy and other ethical principles, including physician paternalism. Here, we explore the ethical background behind shared decision-making, and whether it is genuinely in the patient's best interests or whether it is a cynical solution to encourage more patients to consider conservative care, thus saving limited resources.
No preview · Article · Jun 2013 · Nephrology Dialysis Transplantation
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To explore the relationship between nutritional parameters and psychosocial factors in older people on dialysis. DESIGN: A cross-sectional observational study in prevalent older people on hemodialysis (HD) and peritoneal dialysis (PD). SETTING: A secondary analysis from a quality of life study in older people (Broadening Options for Long-term Dialysis in the Elderly). SUBJECTS: One-hundred and six patients 65 years of age or older and on dialysis for at least 90 days were purposively recruited (HD patients matched to PD patients by age, sex, dialysis vintage, ethnicity and Index of Deprivation). Half were on HD, the mean age was 72.7 years, 72% were male, 92% were from a White ethnic background, and 26% had diabetes. INTERVENTION: The patients attended one visit at which they completed nutritional assessments (3-day food diary, subjective global assessment, handgrip strength, and body mass index) and questionnaires: Short Form-12 (SF-12), the Hospital Anxiety and Depression Scale (HADS), the Mini Mental State Exam, and social networks. MAIN OUTCOME MEASURES: The differences in nutritional parameters between patients on PD and HD were determined by univariate analyses, and the relationships between nutritional intake and demographic, clinical, and psychosocial variables were determined by multivariate analyses. RESULTS: There was no difference in the energy and protein intake and nutritional status between older people on HD and PD. For the whole sample, multivariate analyses found that lower energy intake was related to fewer social networks (P = .002) and lower SF-12 Physical Component Scale (PCS) scores (P = .021). A lower protein intake was related to worsening Index of Deprivation scores (P = .028) and an interaction between SF-12 PCS and presence of possible depression (P = .015). CONCLUSION: Energy and protein intake in older people (regardless of modality) appears to be independently associated with psychosocial variables.
No preview · Article · Apr 2013 · Journal of Renal Nutrition
[Show abstract][Hide abstract] ABSTRACT: Patients with chronic kidney disease, particularly those with diabetes, often have a heavy burden of vascular comorbidity and hence a poor overall prognosis. Unfortunately, patients and their healthcare teams often have unrealistic expectations about outcomes and receive ineffective and often harmful interventions towards their end of life. We need to move away from death being perceived as a failure and realise, instead, that our goal of care at the end of life is to achieve as good a quality of life for the patient as possible. To be able to achieve this, it is important to be realistic about prognosis, be able to recognise predictors of poor outcome and then be able to discuss these with the patient and their family to ensure symptom control, avoid interventions that could do harm and then as the end approaches, determine the wishes of the patient regarding preferred place of care for their inevitable death.
Preview · Article · Feb 2012 · Journal of Renal Care
[Show abstract][Hide abstract] ABSTRACT: Truth telling, a cardinal rule in Western medicine, is not a globally shared moral stance. Honest disclosure of terminal prognosis and diagnosis are regarded as imperative in preparing for the end of life. Yet in many cultures, truth concealment is common practice. In collectivist Asian and Muslim cultures, illness is a shared family affair. Consequently, decision making is family centred and beneficence and non-malfeasance play a dominant role in their ethical model, in contrast to patient autonomy in Western cultures. The 'four principles' are prevalent throughout Eastern and Western cultures, however, the weight with which they are considered and their understanding differ. The belief that a grave diagnosis or prognosis will extinguish hope in patients leads families to protect ill members from the truth. This denial of the truth, however, is linked with not losing faith in a cure. Thus, aggressive futile treatment can be expected. The challenge is to provide a health care service that is equable for all individuals in a given country. The British National Health Service provides care to all cultures but is bound by the legal principles and framework of the UK and aims for equity of provision by working within the UK ethical framework with legal and ethical norms being explained to all patients and relatives. This requires truth telling about prognosis and efficacy of potential treatments so that unrealistic expectations are not raised.
Preview · Article · Dec 2011 · Nephrology Dialysis Transplantation
[Show abstract][Hide abstract] ABSTRACT: Despite a recent increased awareness of the need for quality End of Life (EOL) care for patients with advanced kidney disease, there is no established method for measuring or auditing outcomes relating to EOL care in this population.
We designed a one-page proforma, which was used to collect data on various aspects of EOL care relating to all deaths of patients on dialysis and patients dying on specialist renal wards, over a predefined 8-week period in 10 hospitals in London and South-East England.
One hundred and thirty-eight deaths were recorded over the 8-week study period. The majority of patients (83%) were receiving maintenance haemodialysis prior to their terminal presentation. About 69% of deaths occurred during an in-patient hospital admission-of these, 36% were considered 'unexpected' and most quality markers of good EOL management were significantly less likely to be achieved in these patients, including use of palliative care strategies, good symptom control and overall quality of death. Thirty-six per cent of patients were from various ethnic minorities, and in this group, there was a trend towards lower use of palliative care pathways and lower rates of withdrawal from dialysis.
This study confirms that it is possible to measure many important outcomes relating to quality of EOL care using a proforma completed at the time of death. Our findings suggest that many aspects of good EOL care are under-achieved in our region. This, in part, is due to a failure to recognize the worsening trajectory of the deteriorating patient, resulting in missed opportunities for EOL care planning and appropriate symptom control. Our observations suggest that there is a need for improved education and training in this area, particularly in detection of the dying patient, the value of advance care planning and the utility of tools such as the Liverpool Care Pathway.
Full-text · Article · Oct 2011 · Nephrology Dialysis Transplantation