Analysis of Patient Flow into Dialysis: Role of Education in Choice of Dialysis Modality

Abstract

♦ Background Despite advances in predialysis care, morbidity and mortality remain high. ♦ Objectives To analyze end-stage renal disease (ESRD) patient demographics and clinical data on education on dialysis treatment options, type of chronic renal replacement therapy (RRT), and effects of planned versus non-planned dialysis start. ♦ Methods 621 patients, from 24 Spanish hospitals, who started RRT in 2002. Peritoneal or vascular access at dialysis initiation was considered “planned.” ♦ Results 304 (49%) patients were non-planned and half of them had prior nephrology follow-up. Of the patients with ≥3 months nephrology follow-up (76% of all), only half were educated on dialysis modalities. Dialysis education was associated with planned start in 73.4% versus 26% in non-educated patients ( p < 0.05), shorter follow-up (55 vs 65 months, p = 0.033), more medical visits in the prior year (6.5 vs 4.4, * p < 0.001), more patients starting peritoneal dialysis (31% vs 8.3%*), and more specific follow-up by ESRD unit versus general nephrology care (63% vs 26%*). Non-planned start was associated with older age (63 vs 60.6 years, p = 0.06), fewer medical visits (4.6 vs 6.4*), less education about modality options, and greater use of hemodialysis (92% vs 75%*). Planned patients had better biochemical parameters at start of dialysis. ♦ Conclusion Despite nephrology follow-up, half the patients did not have a planned dialysis start. Planned start was associated with better clinical status. More patients chose peritoneal dialysis when educated about dialysis modality options. ESRD-specific units were more likely to provide patient education.

Home hemodialysis: Beliefs, attitudes, and practice patterns

“…The quality and quantity of pre-dialysis education and the level of support, in the form of a team of specialist nurses, do tend to influence the number of patients choosing a home modality. 13,14 Attending an options class pre-dialysis has been associated with more frequent selection of home dialysis, fewer tunneled HD catheters, and lower mortality risk during the first 90 days of dialysis therapy. 15 The impact of in-hospital pre-dialysis edu-cation program has also been positive on unplanned dialysis starts resulting in increased uptake of home dialysis therapies.…”

A New Paradigm: Home Therapy for Patients Who Start Dialysis in an Unplanned Way

“…A large proportion of patients across Europe start dialysis without permanent vascular access or a peritoneal dialysis (PD) catheter (Lorenzo et al 2004;Marron et al 2005;Aslam et al 2006;Mendelssohn et al 2011). The STARRT study (Study To Assess Renal Replacement Therapy) showed that out of 339 patients on dialysis, only 134 had received a planned start whilst 205 had received a suboptimal start (Mendelssohn et al 2011).…”

“…The STARRT study (Study To Assess Renal Replacement Therapy) showed that out of 339 patients on dialysis, only 134 had received a planned start whilst 205 had received a suboptimal start (Mendelssohn et al 2011). Numerous studies have shown that unplanned/suboptimal dialysis is associated with late referral (referral to a renal unit less than three months before start of dialysis) (Astor et al 2005;Lee et al 2005;Marron et al 2005;Ortega et al 2005;Aslam et al 2006) and often with the need for urgent dialysis (Astor et al 2001(Astor et al , 2005.…”

“…However in the STARRT study, of those 205 patients who had a suboptimal start, 112 had a nephrology follow-up of more than three months before initiation of dialysis (early referral) and only 83 were late referred (Mendelssohn et al 2011). According to some nephrologists, unplanned first dialysis can be caused by service-related factors, acute illness and patient-related reasons which cannot always be avoided (Lorenzo et al 2004;Marron et al 2005;Aslam et al 2006;Mendelssohn et al 2011). More importantly, the STARRT study also showed that sub-optimal starts were associated with higher rates of mortality in the first six months of dialysis and even negated the benefit of an early referral (Mendelssohn et al 2011).…”

“…Furthermore, tunnelled catheters, that are frequently used pending the creation or maturation of fistula, also had higher mortality risk compared with fistulae (Lee et al 2005;Ortega et al 2005). Yet in most situations of unplanned starts to dialysis, even after the temporary CVC has been replaced by a tunnelled line, patients are not offered a choice of therapy and remain on in-centre haemodialysis (ICH) (Astor et al 2001(Astor et al , 2005Marron et al 2005).…”