Background Despite early referral of uraemic patients to nephrological care, suboptimal dialysis initiation (SDI) remains a common problem associated with increased morbimortality. We hypothesized that SDI is related to pre-dialysis care. Methods In the ‘Peridialysis’ study, time and reasons for dialysis initiation (DI), clinical and biochemical data and centre characteristics were registered during the pre- and peri-dialytic period for 1583 end-stage kidney disease patients starting dialysis over a 3-year period at 15 nephrology departments in the Nordic and Baltic countries to identify factors associated with SDI. Results SDI occurred in 42%. Risk factors for SDI were late referral, cachexia, comorbidity (particularly cardiovascular), hypoalbuminaemia and rapid uraemia progression. Patients with polycystic renal disease had a lower incidence of SDI. High urea and C-reactive protein levels, acidosis and other electrolyte disorders were markers of SDI, independently of estimated glomerular filtration rate (eGFR). SDI patients had higher eGFR than non-SDI patients during the pre-dialysis period, but lower eGFR at DI. eGFR as such did not predict SDI. Patients with comorbidities had higher eGFR at DI. Centre practice and policy did not associate with the incidence of SDI. Conclusions SDI occurred in 42% of all DIs. SDI was associated with hypoalbuminaemia, comorbidity and rate of eGFR loss, but not with the degree of renal failure as assessed by eGFR.

Catheter-related infections in peritoneal dialysis (PD) remain a significant complication, and some patients with recurrent exit-site (ESI) and/or tunnel infections may experience external cuff extrusion. In these cases, cuff-shaving has been described as a possible course of treatment. During a 4-year period, there were 44 patients with PD at our department; all received double-cuffed Tenckhoff catheters. Six (13%) never started on PD. Five (13%) of the 38 active PD patients experienced cuff extrusion. Causes of end-stage renal disease (ESRD) were diabetic nephropathy (n = 1), toxic nephropathy (n = 1), hypertensive nephrosclerosis (n = 1), systemic disease (n = 1) and one with unknown cause. PD catheters were inserted by the Department of Surgery and our patients waited a mean of 3.71 weeks (0.57–7.86) from catheter insertion to PD start. Patients were followed up by monthly and even fortnightly during infections. Our cohort experienced two (1–5) ESIs per patient prior to cuff extrusion. Cultures showed growth of Staphylococcus aureus and the patients received dicloxacillin orally 500 mg qid for 3–4 weeks. Of the 38 active PD patients, 5 (13%) developed cuff extrusion with an incidence of 0.20 episodes/patient/year, manifesting on average at 32 weeks (17.3–40.6), due to repeated ESI in four patients and substantial weight loss in one patient. All five underwent cuff-shaving and the ESIs resolved completely in 80% of the cases assisted by supplemental treatment with mupirocin and/or dicloxacillin. There were no complications to the cuff-shaving procedure itself. None of the five patients experienced new ESIs after cuff-shaving had been performed. Cuff-shaving reduces the rate of recurring ESIs. The procedure is safe, if performed correctly, and poses no risk to the patient or the catheter.

Background In patients with end-stage kidney disease (ESKD), home dialysis offers socioeconomic and health benefits compared to in-centre dialysis but is generally underutilized. We hypothesized that pre-dialysis course and institutional factors affect choice of dialysis modality after dialysis initiation (DI). Methods The Peridialysis study is a multinational, multicentre prospective observational study assessing the causes and timing of DI and consequences of suboptimal DI. Clinical and biochemical data, details of the pre-dialytic course, reasons for DI and causes of choice of dialysis modality were registered. Results Among 1587 included patients, 516 (32.5%) were judged unsuitable for home dialysis due to contraindications (384; 24.2%) or no assessment (106; 6.7%; mainly due to late referral and/or suboptimal DI) or death (26; 1.6%). High age, comorbidity, late referral, suboptimal DI, acute illness, and rapid loss of renal function associated with unsuitability. Of the remaining 1071 patients, 700 (65.4%) chose peritoneal dialysis (61.7%) or home haemodialysis (3.6%), while 371 (34.6%) chose in-centre HD. Somatic differences between patients choosing home dialysis and in-centre dialysis were minor; factors linked to choice of in-centre dialysis were late referral, suboptimal DI, acute illness and absence of a “home dialysis first” institutional policy. Conclusions Given a personal choice with shared decision making, 65.4% of ESKD patients choose home dialysis. Our data indicate that the incidence of home dialysis potentially could be further increased to reducing the incidence of late referral and unplanned DI, and, in acutely ill patients, by implementing an educational program after improvement of their clinical condition.

Background and Aims Home dialysis with peritoneal dialysis (PD) or home hemodialysis (HD) has medical and socioeconomic benefits but home dialysis is generally underutilized. While many factors determine choice of initial dialysis modality, starting patients on home dialysis requires timely planning, educational activities and an active program to promote home dialysis. Here we investigated factors including patient suitability, pre-dialysis preparations and institutional factors determining choice of dialysis modality among patients initiating dialysis. Method Choice of dialysis modality was investigated in 1588 consecutive patients (age 63.8 ±15.3 years. 35.8% female; diabetic nephropathy 24.4%) participating in the Peridialysis study, a multinational multi-centre prospective study of causes and timing of planned and unplanned dialysis initiation (DI) over a 3-year period in 15 Nordic and Baltic nephrology departments. All dialysis modalities were available and free of charge to patients. All centres offered pre-dialysis education programs to patients with timely referral. Clinical and biochemical data during the pre-dialytic period, centre data, and reasons for DI and choice of dialysis modality were registered. Results: 516 (32.4%) patients were not offered home dialysis because they were judged to be unsuitable (384; 24%): PD was contraindicated in 338 (21.2%) patients - for physical (142; 8.9%), mental (80, 5.0%) or abdominal (116; 7.3%) reasons and HD was contraindicated in 46 (2.9%) patients. In addition, 106 (6.7%) were not offered home dialysis for various reasons; and deaths before modality choice occurred in 26 (1.6%) patients. Factors associated with unsuitability were high age, comorbidity, late referral (risk ratio, RR, 1.9), inflammation (C-reactive protein >50 mg/L (RR 2.6) and rapid loss of renal function (RR 2.0). Patients who were not assessed for home dialysis comprised mainly patients with late referral (RR 5.8) and/or unplanned DI (RR 9.6). Of the remaining 1072 (67.6%) patients, who had a free choice of modality, 700 (65.3%) chose home dialysis, either PD (661; 61.7%) or home HD ( 39 3.6%) while 372 (34.7%) patients chose centre HD. Factors associated with choice of centre dialysis were late referral (RR 1.8), suboptimal DI (RR 2.0), symptomatic uraemia (RR 1.6) and p-urea >30 mM (2.6). Somatic differences between patients choosing home dialysis and centre dialysis were minor. Independent institutional factors reducing information about home dialysis were treatment at a university hospital (RR 4.3) and absence of an active preference for home dialysis, “home dialysis first” policy (RR 3.0). Conclusion The results of the Peridialysis study indicate that the incidence of home dialysis could be increased by a “home dialysis first” department policy and by efforts to reduce the incidence of late referrals and unplanned DI. Acutely ill patients and patients with unplanned DI may be candidates for home dialysis if assessment of home dialysis suitability and dialysis educational program are performed after their clinical condition has improved. Given a free choice, most patients (65%) choose home dialysis.

Background: Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI. Methods: Among 1580 patients participating in the Peridialysis study, a prospective study of causes and timing of DI, features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice were registered. Patients were followed for 12 months or until transplantation.Results: First-year mortality was 20.2%. In addition to age and comorbid factors, independent factors predicting death were: clinical contraindications to PD or HD, a rapidly falling eGFR before DI, suboptimal DI, acidosis, high C-reactive protein, signs of overhydration (pulmonary stasis) and cerebral symptoms at DI while eGFR at DI was not. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD.Conclusions: First-year mortality in incident dialysis patients was associated with high age, comorbidity, worsening of kidney failure and clinical symptoms, acidosis, inflammation, and suboptimal DI while eGFR at DI and dialysis modality did not appear as predictors. These findings support the view that choice of dialysis modality among patients who are able to make an informed decision can be based on patient preference.