Home dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.

Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams.

Hemodialysis Program in a Subacute Care Facility for ESRD Patients With Tracheostomy

Background: ESRD patients with tracheostomy require long-term mechanical ventilation in addition to need for maintenance dialysis. Due to regulations in California, majority of such patients have prolonged acute hospital stays due to lack of availability of a lower level of care facility, capable of providing ventilation care and hemodialysis. Need for these services increased during the COVID 19 pandemic. Kaiser Permanente Northern California (KPNC) is an integrated health care system providing health care for 4.6 million members. Partnering with a large dialysis organization (LDO) and a local Subacute Care facility (SAC), a program has been developed to provide home hemodialysis for patients requiring long-term mechanical ventilation using Low Dialysate Volume Approach (LDVA) machines. Method(s): The program was initiated in Q4 2017. A set of clinical criteria for admission was developed between the LDO, SAC and KPNC. Weekly meetings with physicians, dialysis nurses, and SAC staffs were conducted to review the potential candidates currently hospitalized in one of twenty-one KPNC hospitals. Dialysis has been performed by a HD nurse four times a week (M-T-Th-F) for 3-3.5 hours for each dialysis treatment. Each treatment was conducted using a LDVA machine with standard LDVA prescriptions using a Watson calculator to achieve a weekly Kt/V above 2.1. Result(s): Since the inception of the program, 45 patients have been admitted to the program, 24 female and 21 male patients. The mean age is 65 (+/-13) on the date of admission. The average length of stay per patient at an acute hospital prior to admission was 125 days, and after the admission, the total days in the SAC is 7,498 days, an average of 167 days per person. Total acute hospital re-admission days after admission to the program is 1,071 days, an average of 25 days per patient (range: 0 to 115 days). Nine patients are currently residing in the SAC. Conclusion(s): It is feasible to provide hemodialysis care for patients requiring long term mechanical ventilation at the appropriate level of care. This approach reduces the patient length of stay (LOS) in acute hospitals and burden to critically stretched healthcare system. Further discussion with local regulatory agencies is needed to develop additional models of care to effectively deliver dialysis to patients requiring facility-based long-term care.

Impact of Inpatient Tele-Nephrology Treatment Outcomes in Rural Alabama

Background: Access to nephrology care including dialysis in rural Alabama (AL) hospitals is lacking. The University of Alabama at Birmingham (UAB) with Sanderling Inc. started inpatient tele-nephrology (TN) services in 2019 and currently serves 3 rural AL hospitals. Since the COVID-19 pandemic, transfer to TN-equipped hospitals in AL played a pivotal role for patients needing nephrology services when primary referral centers were at capacity. Method(s): TN services were 100% virtual and video-based. Consults were completed by UAB nephrology faculty. Home hemodialysis machine (HHD) was used to provide kidney replacement therapy (KRT) in the hospital, with aid of inpatient dialysis technicians supervised remotely by TN dialysis nurses. TN consults were evaluated from Jun 2019 to Dec 2021. Retrospective chart review for pre-defined outcomes was performed and analyzed. Result(s): There were 694 inpatient TN encounters. Mean age was 64 (18-96) yr. 74% of consultations involved black patients. Mean stay was 6 d. 44% were ICU patients;18% were COVID-19 positive. AKI and known ESKD patients contributed to 48% and 44% consults, respectively. 11% had AKI necessitating KRT. 20% and 13% of consults involved hyperkalemia and dysnatremias, respectively. 792 dialysis treatments were performed with 11% complicated by intradialytic hypotension (IDH). Patients were discharged 64% and transferred to higher level of care 18% of the time. 90 patients expired. 66% of deaths were attributable to COVID-19. Preliminary economics analysis at the hospital with the most consults showed increase in case-mix index and higher census since implementation of TN services. Conclusion(s): Inpatient TN in community hospitals in rural AL provided essential nephrology care to underserved populations amidst a pandemic limiting transfer to nephrology-staffed medical centers at capacity. Most patient encounters resulted in discharge without need for transfer to bigger centers thus saving vital time and resources. Dialysis safety was favorable with low IDH prevalence likely given HHD use. TN services can be beneficial for nephrology care in remote community hospitals with further studies warranted.

Prevalence of Depression in an Urban, Predominantly Black ESKD Population During the COVID-19 Pandemic

Background: The COVID-19 pandemic has had far-reaching implications in terms of physical and mental health ramifications, and minority communities have been disproportionately impacted;particularly, prevalence of depression increased. Throughout the pandemic, ESKD patients have continued thrice-weekly in-center hemodialysis sessions or home therapies. We explored whether there was an increase in depression prevalence after the start of the pandemic in our urban predominantly Black ESKD population. Method(s): We used data from social worker-administered PHQ-2 questionnaire depression screenings (required by Centers for Medicare & Medicaid Services) in eligible patients treated at four Emory University affiliated in-center dialysis units and three home dialysis units from 2018-2019 (pre-pandemic) to 2020-2021 (pandemic). Excluded from this study were patients with no assessments or incomplete assessments. Data were analyzed using chi-square tests comparing the prevalence of depression in pre-pandemic versus pandemic period. Result(s): In 2021, 91.5% of our patients were Black. There were 2433 in-center patient depression scores and 586 home dialysis patient depression scores. Excluded from the study were 1045 patients in the in-center and 214 patients in the home population. Of the 2433 patient scores analyzed in the in-center group, 1289 were pre-pandemic and 1144 were in the pandemic period. 155 (12%) in-center patient scores in the prepandemic period were classified as depressed while 128 (11.2%) in-center patient scores during the pandemic were classified as depressed (two-sided p-value 0.5272). Of the 586 home dialysis patient scores, 325 were pre-pandemic and 261 in the pandemic period. 71 (21.8%) patient scores in the pre-pandemic period had a positive depression screening while 29 (11.1%) patient scores during the pandemic period had depression (two-sided p-value 0.0006). Conclusion(s): We did not observe an increase in depression prevalence during the COVID-19 pandemic in in-center dialysis patients, and surprisingly observed a statistically significant decrease in depression among our home dialysis patients. The decrease in depression in our home dialysis patients during the pandemic may reflect being at home is a protective mechanism, and this observation should be further investigated.

Isolated Anti-GBM Disease and COVID-19 Vaccination

Introduction: IgA nephropathy is the most reported glomerulonephritis post-COVID vaccination. Other reported cases include atypical anti-GBM nephritis, among others. Treatment consists of immunosuppressants and plasmapheresis with renal replacement therapy. Renal outcomes have varied. A case is presented of isolated anti-GBM nephritis in a patient whose renal injury occurred weeks after receiving a booster dose of COVID vaccine. Case Description: A 59-year-old male with recent history of ureteral stones with stent placement, travel history in the last 6 months and use of doxycycline for suspected Lyme's disease in the last 3 months presented to the emergency department for decreased urine output, fevers, and arthralgias. He also received a Pfizer COVID vaccine booster 6 weeks ago. His symptoms had worsened in the last 2 weeks. On initial evaluation, he was noted to have stage 3 acute kidney injury (AKI) with creatinine 5.3 mg/dL. Although he had findings of nephrolithiasis, no ureteral obstruction or hydronephrosis were noted on imaging. He received extensive infectious work up which was all negative. Hemodialysis was initiated on day 7 for metabolic derangements and volume overload. After infectious work up was negative, renal biopsy was perfromed revealing linear IgG deposits. Serum anti-GBM antibodies were positive. Despite receiving plasmapheresis, cyclophosphamide and prednisone, the patient continued to require dialysis and was discharged on home hemodialysis. Discussion(s): The development of AKI with systemic symptoms occurred about 6 weeks following his COVID vaccine, longer than previously reported cases. The patient also has a history of nephrolithiasis. At this time, direct association of this patient's anti-GBM disease with the COVID vaccine is unclear however remains a clinical consideration. The presentation of anti-GBM disease is unique as disease is limited to renal involvement. (Figure Presented).

Exploring the Evidence: Focusing on the Fundamentals Exploring the Evidence: Considerations for the Dialysis Practice Setting Approach to Staffing

Nursing remains one of the most in-demand jobs in the American workforce. The impact of the COVID-19 pandem-ic has created strain on nursing resources throughout the health care industry and drawn attention to longstanding workforce issues. Inadequate staffing is often a multidi-mensional problem that warrants a comprehensive assessment of elements that may contribute to recruit-ment and retention issues. In the dialysis practice setting, nursing shortages remain an ongoing issue due to an aging workforce and ongoing issues for recruiting nurses both new and skilled into the field of nephrology. This article explores the evidence on approaches to staffing in the dial-ysis practice setting by defining core elements to consider when designing a staffing model. These elements include federal/state regulations, patient acuity, staff ratios, work-force perceptions, patient outcomes, and dialysis modali-ties offered.

Impact of coronavirus disease (COVID-19) on home dialysis: Experiences of home dialysis nurses in Australia and Canada

Objective The spread of the coronavirus disease (COVID-19) pandemic has created an opportunity to re-evaluate and refine existing models of healthcare delivery for patients receiving dialysis at home. This study aims to explore the experiences of home dialysis nurses during the pandemic. Methods This was an observational study via survey. Participants were recruited through the home dialysis nursing networks in Australia and the province of Ontario, Canada. Results A total of 45 nurses responded to the survey, 53% (n=24) from Australia and 47% (n=21) from Ontario, Canada. The nurses identified that most units had moved to 'virtual' patient visits, only seeing those patients with urgent issues in person. They also reported problems with delivery of supplies for patients, implementation of social distancing during training, difficulties for patients with navigation of telehealth platforms for `virtual' clinic visits, and staffing shortages with staff needing to stay home with any suspected COVID-19 symptoms or contact. The nurses perceived that being flexible in their roles and working hours were helpful during the pandemic, while being ready to adapt at short notice was also important. Conclusion During the COVID-19 pandemic, patients receiving home dialysis have benefited from fewer healthcare facility visits and a greater ability to adhere to social distancing measures, thus limiting exposure to COVID-19 infection. Yet, patients may face challenges relating to delay or back order of dialysis supplies and social isolation, and may struggle with telehealth platforms. Our learning experience from this pandemic will help us identify the challenges encountered and measures taken to address them.

Impact of telehealth interventions added to peritoneal dialysis-care: a systematic review.

BACKGROUND: Telehealth could potentially increase independency and autonomy of patients treated with peritoneal dialysis (PD). Moreover, it might improve clinical and economic outcomes. The demand for telehealth modalities accelerated significantly in the recent COVID-19 pandemic. We evaluated current literature on the impact of telehealth interventions added to PD-care on quality of life (QoL), clinical outcomes and cost-effectiveness. METHODS: An electronic search was performed in Embase, PubMed and the Cochrane Library in order to find studies investigating associations between telehealth interventions and: i. QoL, including patient satisfaction; ii. Standardized Outcomes in Nephrology (SONG)-PD clinical outcomes: PD-related infections, mortality, cardiovascular disease and transfer to hemodialysis (HD); iii. Cost-effectiveness. Studies investigating hospitalizations and healthcare resource utilization were also included as secondary outcomes. Due to the heterogeneity of studies, a meta-analysis could not be performed. RESULTS: Sixteen reports (N = 10,373) were included. Studies varied in terms of: sample size; design; risk of bias, telehealth-intervention and duration; follow-up time; outcomes and assessment tools. Remote patient monitoring (RPM) was the most frequently studied intervention (11 reports; N = 4982). Telehealth interventions added to PD-care, and RPM in particular, might reduce transfer to HD, hospitalization rate and length, as well as the number of in-person visits. It may also improve patient satisfaction. CONCLUSION: There is a need for adequately powered prospective studies to determine which telehealth-modalities might confer clinical and economic benefit to the PD-community.

Family-Friendly & Work-Friendly Hybrid Hemodialysis: Combination Home Hemodialysis and In-Center Hemodialysis Regimen

Hybrid dialysis is traditionally identified as the combined utilization of peritoneal dialysis (PD) and hemodialysis (HD) in patients with ESRD. In this case study, we have described the successful application of a new Hybrid HD model that combined Home HD + in-center HD. To our knowledge, our report is the first of its kind and was designed and implemented primarily for the patient’s wellbeing;to suit the new exigencies and circumstances at his home, family, and workplace, on a long-term, sustainable basis. Our Home Dialysis Program this year encountered major family-related and work-related constraints that had increasingly prevented a 41-year-old man on home HD from completing the prescribed four times weekly HD sessions. He works full-time and is on-call on weekends plus has 2 young children under the age of 5 resulting in long days and multiple missed HD sessions. HD inadequacy led to worsening physiology and a risk of being de-listed from a kidney transplant program. He was successfully transitioned to a new hybrid dialysis regimen of twice-weekly Home HD + twice weekly in-center HD. We were able to enable a young family to continue with some form of sustainable HD care while circumnavigating the intricacies of the COVID-19 pandemic, childcare, work pressure, and family health challenges, while waiting for a kidney transplant. The potential burden of home dialysis on the patients and caregivers cannot be overemphasized. There is therefore an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. In response, patients, payers, regulators and health-care systems are increasingly demanding improved value, which can only come about through truly patient-centered innovation that supports high-quality high-value care. We posit that a large-scale review, evaluation, and extended study of our new hybrid HD care model should be supported by the appropriate public health and governmental authorities, both here in the USA and globally, as we continue to find new, innovative ways to improve the health of the ever-burgeoning ESRD population around the world.

ESKD Patient Experiences During the COVID-19 Pandemic: A Survey Study

End stage kidney disease (ESKD) patients are vulnerable to medical and psychosocial difficulties. We aimed to identify specific concerns for ESKD patients during the early months of the COVID-19 pandemic. Surveys were administered to adult ESKD patients receiving dialysis in three units run by a large dialysis organization affiliated with an academic nephrology practice. Multiple choice and open-ended questions were used to assess patients’ perceptions of access to care and essentials of daily living, and effects of changes in dialysis schedules or prescriptions. Screening questions were used to assess patient anxiety and depression. 172 ESKD patients on dialysis were surveyed. Participants on home dialysis modalities [peritoneal dialysis (PD) or home hemodialysis (HHD)] more commonly reported feeling “very connected” to their dialysis care teams compared to patients on in-center hemodialysis (ICHD) (PD: 74.1%;HHD: 66.7%;ICHD: 62.3%). Patients who identified as White more commonly reported feeling “very connected” compared to patients who identified as non-White (White: 74.4%;Black/African American: 60.5%;Hispanic: 69.6%). Patients with histories of anxiety or depression more commonly reported feeling less cared for during the pandemic. 16.9% of participants reported new transportation issues, 6.4% reported difficulty obtaining medications, and 9.3% reported difficulty getting groceries. A minority of patients met screening criteria for depression or anxiety, though patients with self-reported histories of anxiety or depression had higher screening scores. Five themes emerged as influencing patient experiences: 1) the positive influence of relationships with dialysis staff;2) the value of interactions with family or other caretakers;3) difficulties with access to care;4) changes in physical and mental health;and 5) awareness of, and response to, the COVID-19 pandemic. Our study identifies sub-populations of ESKD patients who may be more vulnerable during the COVID-19 pandemic: those with histories of anxiety or depression, non-White patients, and patients on ICHD. Use of home dialysis modalities may be associated with better patient perceptions of care.

Peritoneal catheter insertion: combating barriers through policy change.

Barriers to accessing home dialysis became a matter of life and death for many patients with kidney failure during the coronavirus disease 2019 (COVID-19) pandemic. Peritoneal dialysis (PD) is the more commonly used home therapy option. This article provides a comprehensive analysis of PD catheter insertion procedures as performed around the world today, barriers impacting timely access to the procedure, the impact of COVID-19 and a roadmap of potential policy solutions. To substantiate the analysis, the article includes a survey of institutions across the world, with questions designed to get a sense of the regulatory frameworks, barriers to conducting the procedure and impacts of the pandemic on capability and outcomes. Based on our research, we found that improving patient selection processes, determining and implementing correct insertion techniques, creating multidisciplinary teams, providing appropriate training and sharing decision making among stakeholders will improve access to PD catheter insertion and facilitate greater uptake of home dialysis. Additionally, on a policy level, we recommend efforts to improve the awareness and feasibility of PD among patients and the healthcare workforce, enhance and promulgate training for clinicians-both surgical and medical-to insert PD catheters and fund personnel, pathways and physical facilities for PD catheter insertion.

DEVELOPMENT OF HOME DIALYSIS PATIENT SUPPORT SYSTEM USING CLOUD SYSTEM II-ADDITION OF EXERCISE THERAPY FUNCTION

BACKGROUND AND AIMS: The number of patients requiring home dialysis in Japan is increasing due to COVID-19 and the aging of the population. Home haemodialysis has been performed in Japan since the 1960s. However, as of March 2019, there were 720 home haemodialysis patients in Japan, which is only 0.2% of the total number of dialysis patients. The possible causes are as follows. The number of home haemodialysis patients has not increased markedly due to safety concerns as home haemodialysis patients perform dialysis at home, and the out-ofpocket costs are high. In addition, patients and caregivers must be able to manage themselves, and the burden on both patients and caregivers is heavy. Therefore, the Ministry of Health, Labour and Welfare (Japan) has advocated the need for home patients to share information with medical institutions to improve their quality of life, including COVID-19 measures. We have built a system to support home dialysis patients. Here, we have added an exercise therapy function to this system to encourage patients to continue exercising. METHOD: The items recorded/displayed in the patient's home peritoneal dialysis support system included records such as time, blood pressure, blood glucose level, urine volume, meal content, replacement start time, dialysate/plasma ratio, drainage volume, injection volume, water content and water removal and drainage. These inputs were entered via drop-down menus and displayed visually in graphs or by uploading images. The medical staff could see photographs of the affected areas and of meals entered by the patient. Patients could also share their opinions and treatment schedules with the medical staff at the medical institution. In addition, when exercising, the patients used an ergometer that allowed them to sit or lie down. The developed system incorporates records of the patient's exercises. Data were captured directly from the ergometer into the developed system in CSV format and could also be entered manually via drop-down menus. RESULTS: Using the developed system, we were able to enter and view patients' vital data and display photographs showing the color and volume of the drainage pack. By viewing these photographs, the medical staff could confirm the photographs of the affected areas, the color of the packs and the contents of the patients' meals. In addition, displaying the patient's vital records in a graph allowed for visual evaluation over time, which was useful when giving advice to patients. Using the two-way communication function, patients were also able to share their opinions and treatment schedules with the medical staff of the medical institution. Patients can now consult with medical staff, making their homes more like part of the hospital and giving them greater peace of mind. Figure 1 shows an example of the display of the developed system. Figure 2 shows an example of the patient's pedaling exercise results input from the ergometer. The amount of pedal movement performed by the patient was conserved through the dynamo and used to charge mobile devices. This allows the patient to charge their mobile devices while exercising, thus encouraging them to continue exercising. CONCLUSION: We have developed a support system for home haemodialysis patients that allows the input and display of patients' vital records and consultation with medical staff online. We have added a function to the system to encourage home haemodialysis patients to continue exercising. By using the developed system, patients can now perform home dialysis, including continuous exercise safely and with peace of mind, and healthcare professionals can access all medical information of patients, including changes over time. (Figure Presented).

THE INFLUENCE OF ONLINE KIDNEY SCHOOL ON DIALYSIS CHOICE

BACKGROUND AND AIMS: Factors influencing dialysis choice are multifaceted. Detailed and unbiased information is pivotal in order to assist patients in making decisions. Hence, patient education is a cornerstone in the treatment of advanced chronic kidney disease. At the hospital of Southern Jutland, a kidney school has existed for more than 15 years teaching patients about their illness and treatment options at end-stage renal disease (ESRD). Due to the coronavirus disease (COVID-19) pandemic, an online kidney school (OKS) was established. We present the latest results of this ongoing study regarding the change of preferences of ESRD treatment options among patients after participation in online renal education. METHOD: The OKS consists of a 3-h synchronous class taught by a nephrologist and a dialysis nurse combined with asynchronous short films on treatment options and advice from a dietitian. The OKS has been held six times with 45 patients in total. A questionnaire was distributed to participants before and after the OKS. Patients were asked to choose between center haemodialysis, home haemodialysis, peritoneal dialysis, transplantation, maximal conservative medical treatment and 'not enough information to make the decision'. RESULTS: Out of the 45 patients, 36 patients answered the questionnaire before OKS and of those, 19 also answered the questionnaire after OKS. A total of 76% % of the participants were male, 52% answered the questionnaire on their own and 48% answered the questions together with a relative. The percentage of patients not feeling informed enough to make the decision decreased from 56% prior to participation in OKS in comparison to 32% following participation in OKS. The percentage of patients who prefer peritoneal dialysis as their ESRD treatment of choice increased from 6% to 32%. CONCLUSION: Online education on treatment choices for end-stage renal patients leads to change of treatment preferences. This is especially true for peritoneal dialysis. The OKS is designed to help patients make an informed decision on treatment options in ESRD. Although the number of patients feeling unsure about what kind of treatment to choose is decreased, the number of patients unsure about the best treatment option for them remains high. These patients require a follow-up consultation in order for them to make the final decision for ESRD treatment. The number of patients who answered the questionnaire prior to OKS is higher in comparison to after OKS. However, this is an ongoing study and we will be able to confirm or dismiss these preliminary findings at a later stage. (Figure Presented).

A FOUR-YEAR ANALYSIS ON HOME DIALYSIS AT THE NORTH BRISTOL NHS TRUST-WHAT TO DO NEXT?

BACKGROUND AND AIMS: Home dialysis, including peritoneal dialysis (PD) and home hemodialysis (HHD), has been associated with improved patient autonomy, quality of life and overall cost effectiveness (Weinhandl et al. Propensity matched mortality comparison of incident hemodialysis and peritoneal dialysis patients. J Am Soc Nephrol. 2010;21: 499-506). The 2021 Get It Right First Time (GIRFT) Renal report revealed that home dialysis patients were at a lower risk of contracting and dying of coronavirus disease 2019 (COVID-19), compared to those who received in-center hemodialysis (ICHD) (2). Despite these advantages, uptake of home dialysis is still lower than that of ICHD. The aim of our study was to analyse the numbers and reasons for home dialysis withdrawal at the North Bristol NHS Trust between 2018 and 2021. METHOD: All patients on PD and HHD between 2018 and 2021 were included. Analysis of the episodes that led to home dialysis cessation was carried out. As some patients required withdrawal more than once during the 4-year period, each episode of dropout was considered separately. The prevalence rate of patients on home dialysis was calculated. RESULTS: The total number of patients on home dialysis increased from 74 in 2018 to 98 in 2021. The male: female ratio of patients was 3:2 with an average age of 58.3. The number of patients on PD increased from 58 at the end of 2018 to 82 in 2021. The number of patients on HHD remained stable over the years, with an average of 16. The prevalence rate of home dialysis was 17.1% at the end of 2021. Figure 1 shows the total number of patients who started and dropped out of home dialysis every year. The number of patients initiating PD was 58 in 2018, 55 in 2019, 37 in 2020 and 59 in 2021. The number of dropouts was 57 in 2018, 41 in 2019, 29 in 2020 and 43 in 2021. The dip in number of patients initiated on PD in 2020 can be attributed to the start of the COVID-19 pandemic, when elective procedures were temporarily withheld. On the other hand, a lower number dropped out during 2020. This may be explained by the emphasis given to self-isolation rules and persistence with home dialysis during the outbreak. The overall increase in PD uptake in 2021 may be explained by the establishment of a new specialist clinic that promotes the uptake of home dialysis. The initiation of a new peer support service group in 2021 may also have contributed. The number of patients initiating and withdrawing from HHD followed the same pattern, with a significant dip in 2020. Figure 2 demonstrates the reasons for withdrawal from PD over the study period. The most prevalent reasons were PD-related infections and transplantation. The observed figures for transplantation reflect the continuous efforts involved in the maintenance of a successful transplant programme. The figure also shows that termination of PD due to failure was highest in 2021. The authors postulate that this surge might be due to the previous year's low PD dropout rate. The leading reason for stopping HHD was transplantation. Other reasons included recovery of renal function and switching to conservative management. Death led to one dropout/year in 2018-20, but none in 2021. CONCLUSION: Around 17% of the NBT's total dialysis population is currently on home dialysis. The commonest reasons for termination of home dialysis were transplantation and PD-related infections. The GIRFT report recommends that all adult renal units in the UK should reach a minimum prevalence rate of 20% of their dialysis population on home dialysis by the end of 2024 (Lipkin et al. Renal medicine: Get It Right First Time (GIRFT) Programme National Specialty Report. March 2021. NHS England and NHS Improvement). Whereas our statistic falls slightly short of this, we aim to reach this target through various strategies. These include continued audit, home dialysis campaign, continued psychological services and a reduction in waiting time for PD catheter insertion.

ETC Model: How One Small Dialysis Organization Is Navigating Uncharted Policy Waters.

The ETC model proposes to increase access to home dialysis and transplant for patients with ESRD. Implementation of this model is happening while many dialysis organizations are still suffering the far-reaching effects of the coronavirus disease 2019 (COVID-19) pandemic. In addition, the model has the potential to negatively affect small and independent dialysis organizations disproportionately. It incentivizes home dialysis over transplant and promotes development of new home dialysis programs, rewards achievement over improvement, and places an excessive burden on small and independent dialysis organizations. Advantages of the program include the focus on self-care as an acceptable alternative to home dialysis for some patients and the potential for some organizations to make improvements in care with increased reimbursements. The authors hope that the Centers for Medicare and Medicaid Services will address many of these concerns in updated rulemaking and guidance.