Can economic incentives increase the use of home dialysis?

There are advantages to home dialysis for patients, and kidney care programs, but use remains low in most countries. Health-care policy-makers have many levers to increase use of home dialysis, one of them being economic incentives. These include how health-care funding is provided to kidney care programs and dialysis facilities; how physicians are remunerated for care of home dialysis patients; and financial incentives-or removal of disincentives-for home dialysis patients. This report is based on a comprehensive literature review summarizing the impact of economic incentives for home dialysis and a workshop that brought together an international group of policy-makers, health economists and home dialysis experts to discuss how economic incentives (or removal of economic disincentives) might be used to increase the use of home dialysis. The results of the literature review and the consensus of workshop participants were that financial incentives to dialysis facilities for home dialysis (for instance, through activity-based funding), particularly in for-profit systems, could lead to a small increase in use of home dialysis. The evidence was less clear on the impact of economic incentives for nephrologists, and participants felt this was less important than a nephrologist workforce in support of home dialysis. Workshop participants felt that patient-borne costs experienced by home dialysis patients were unjust and inequitable, though participants noted that there was no evidence that decreasing patient-borne costs would increase use of home dialysis, even among low-income patients. The use of financial incentives for home dialysis-whether directed at dialysis facilities, nephrologists or patients-is only one part of a high-performing system that seeks to increase use of home dialysis.

Clinical safety and performance of VIVIA: a novel home hemodialysis system.

Background: The VIVIA Hemodialysis System (Baxter Healthcare Corporation, Deerfield, IL, USA) was designed for patient use at home to reduce the burden of treatment and improve patient safety. It has unique features including extended use of the dialyzer and blood set through in situ hot-water disinfection between treatments; generation of on-line infusible-quality dialysate for automated priming, rinseback and hemodynamic support during hypotension and a fully integrated access disconnect sensor. Methods: The safety and performance of VIVIA were assessed in two clinical studies. A first-in-man study was a prospective, single-arm study that involved 22 prevalent hemodialysis (HD) patients who were treated for ∼4 h, four times a week, for 10 weeks. A second clinical study was a prospective, single-arm study (6-8 h of dialysis treatment at night three times a week) that involved 17 prevalent patients treated for 6 weeks. Results: There were 1114 treatments from the two studies (first-in-man study, 816; extended duration study, 298). Adverse events (AEs) were similar in the two studies to those expected for prevalent HD patients. No deaths and no device-related serious AEs occurred. Adequacy of dialysis ( Kt / V ) urea in both clinical trials was well above the clinical guidelines. VIVIA performed ultrafiltration accurately as prescribed in the two studies. The majority of patients achieved 10 or more uses of the dialyzer. Endotoxin levels and bacterial dialysate sampling met infusible-quality dialysate standards. Conclusion: These results confirm the safety and expected performance of VIVIA.

Prescriptions of dialysate potassium concentration during short daily or long nocturnal (high dose) hemodialysis.

The prescription of dialysate potassium concentration during short daily and long nocturnal (high dose) hemodialysis (HD) is challenging due to limited clinical experience with such modalities. The aim here is to propose a quantitative approach for prescribing dialysate potassium concentrations during high-dose HD. Potassium kinetic parameters based on a pseudo one-compartment model from 547 patients participating in the HEMO Study were used for prediction purposes in this study. Patients were categorized based on the prescribed dialysate potassium concentration during thrice weekly HD as 1K (mean of 1.02 mEq/L, N = 60), 2K (2.01 mEq/L, N = 437), or 3K (3.01 mEq/L, N = 50). Dialysate potassium concentrations were then predicted for each patient during short daily and long nocturnal HD based on a pseudo one-compartment model to maintain the identical weekly dialytic potassium removal and predialysis serum potassium concentration as during thrice weekly HD. Predicted prescribed dialysate potassium concentrations for short daily HD were 0.18-0.45 mEq/L higher than during thrice weekly HD but were approximately 4 (3.72-4.26) mEq/L for all patients during long nocturnal HD. The intradialytic decrease in serum potassium concentration was predicted to be reduced by more than one-half during short daily HD and by approximately three-quarters during long nocturnal HD of that during thrice weekly HD. Prescribed dialysate potassium concentration during high-dose HD modalities can be quantitatively predicted using a pseudo one-compartment kinetic model. High-dose HD modalities may improve clinical outcomes by reducing intradialytic decreases in serum potassium.

Bettering the lives of patients with end-stage renal disease with HomeChoice Claria with Sharesource: an interview with Dr. Bruce Culleton.

Interview with Dr. Bruce Culleton, Vice President, renal therapeutic area lead at Baxter by Tasnim Zahri (Commissioning Editor) I was fortunate enough to meet Dr. Bruce Culleton, Vice President, renal therapeutic area lead at Baxter (Deerfield, IL, USA), during the European Renal Association - European Dialysis and Transplant Association conference in London to discuss Baxter's newest dialysis system; the HomeChoice Claria automated peritoneal dialysis system with the Sharesource web-based connectivity platform. Recently awarded a CE mark, HomeChoice Claria with Sharesource is hoped to better the lives of patients with end-stage renal disease, enable effective connectivity between patients and clinicians and pave the way toward improved individualized care.

Evidence-based decision-making 4: Development and limitations of clinical practice guidelines.

Clinical practice guidelines are systematically developed statements to assist practitioners and patients reach appropriate health care decisions. If developed properly, clinical practice guidelines assimilate and translate an abundance of evidence published on a daily basis into practice recommendations and, in doing so, reduce the use of unnecessary or harmful interventions, and facilitate the treatment of patients to achieve maximum benefit and minimum risk at an acceptable cost. Traditionally, clinical practice guidelines were consensus-based statements, often riddled with expert opinion. It is now recognized that clinical practice guidelines should be developed according to a transparent process involving principles of bias minimization and systematic evidence retrieval and review, with a focus on patient-relevant outcomes. The process for the development, implementation, and evaluation of clinical practice guidelines is reviewed in this chapter.

High-dose hemodialysis versus conventional in-center hemodialysis: a cost-utility analysis from a UK payer perspective.

OBJECTIVE: To investigate the cost-effectiveness of high-dose hemodialysis (HD) versus conventional in-center HD (ICHD), over a lifetime time horizon from the UK payer's perspective. METHODS: We used a Markov modeling approach to compare high-dose HD (in-center or at home) with conventional ICHD using current and hypothetical home HD reimbursement tariffs in England. Sensitivity analyses tested the robustness of the results. The main outcome measure was the incremental cost-effectiveness ratio (ICER) expressed as a cost per quality-adjusted life-year (QALY). RESULTS: Over a lifetime, high-dose HD in-center (5 sessions/wk) is associated with higher per-patient costs and QALYs (increases of £108,713 and 0.862, respectively) versus conventional ICHD. The corresponding ICER (£126,106/QALY) indicates that high-dose HD in-center is not cost-effective versus conventional ICHD at a UK willingness-to-pay threshold of £20,000 to £30,000. High-dose HD at home is associated with lower total costs (£522 less per patient) and a per-patient QALY increase of 1.273 compared with ICHD under the current Payment-by Results reimbursement tariff (£456/wk). At an increased home HD tariff (£575/wk), the ICER for high-dose HD at home versus conventional ICHD is £17,404/QALY. High-dose HD at home had a 62% to 84% probability of being cost-effective at a willingness-to-pay threshold of £20,000 to £30,000/QALY. CONCLUSIONS: Although high-dose HD has the potential to offer improved clinical and quality-of-life outcomes over conventional ICHD, under the current UK Payment-by Results reimbursement scheme, it would be considered cost-effective from a UK payer perspective only if conducted at home.

Potassium kinetics during hemodialysis.

Hyperkalemia in hemodialysis patients is associated with high mortality, but prescription of low dialysate potassium concentrations to decrease serum potassium levels is associated with a high incidence of sudden cardiac arrest or sudden death. Improved clinical outcomes for these patients may be possible if rapid and substantial intradialysis decreases in serum potassium concentration can be avoided while maintaining adequate potassium removal. Data from kinetic modeling sessions during the HEMO Study of the dependence of serum potassium concentration on time during hemodialysis treatments and 30 minutes postdialysis were evaluated using a pseudo one-compartment model. Kinetic estimates of potassium mobilization clearance (K(M)) and predialysis central distribution volume (V(pre)) were determined in 551 hemodialysis patients. The studied patients were 58.8 ± 14.4 years of age with predialysis body weight of 72.1 ± 15.1 kg; 306 (55.4%) of the patients were female and 337 (61.2%) were black. K(M) and V(pre) for all patients were non-normally distributed with values of 158 (111, 235) (median [interquartile range]) mL/min and 15.6 (11.4, 22.8) L, respectively. K(M) was independent of dialysate potassium concentration (P > 0.2), but V(pre) was lower at higher dialysate potassium concentration (R = -0.188, P < 0.001). For patients with dialysate potassium concentration between 1.6 and 2.5 mEq/L (N = 437), multiple linear regression of K(M) and V(pre) demonstrated positive association with predialysis body weight and negative association with predialysis serum potassium concentration. Potassium kinetics during hemodialysis can be described using a pseudo one-compartment model.

The financial impact of increasing home-based high dose haemodialysis and peritoneal dialysis.

BACKGROUND: Evidence suggests that high dose haemodialysis (HD) may be associated with better health outcomes and even cost savings (if conducted at home) versus conventional in-centre HD (ICHD). Home-based regimens such as peritoneal dialysis (PD) are also associated with significant cost reductions and are more convenient for patients. However, the financial impact of increasing the use of high dose HD at home with an increased tariff is uncertain. A budget impact analysis was performed to investigate the financial impact of increasing the proportion of patients receiving home-based dialysis modalities from the perspective of the England National Health Service (NHS) payer. METHODS: A Markov model was constructed to investigate the 5 year budget impact of increasing the proportion of dialysis patients receiving home-based dialysis, including both high dose HD at home and PD, under the current reimbursement tariff and a hypothetically increased tariff for home HD (£575/week). Five scenarios were compared with the current England dialysis modality distribution (prevalent patients, 14.1% PD, 82.0% ICHD, 3.9% conventional home HD; incident patients, 22.9% PD, 77.1% ICHD) with all increases coming from the ICHD population. RESULTS: Under the current tariff of £456/week, increasing the proportion of dialysis patients receiving high dose HD at home resulted in a saving of £19.6 million. Conducting high dose HD at home under a hypothetical tariff of £575/week was associated with a budget increase (£19.9 million). The costs of high dose HD at home were totally offset by increasing the usage of PD to 20-25%, generating savings of £40.0 million - £94.5 million over 5 years under the increased tariff. Conversely, having all patients treated in-centre resulted in a £172.6 million increase in dialysis costs over 5 years. CONCLUSION: This analysis shows that performing high dose HD at home could allow the UK healthcare system to capture the clinical and humanistic benefits associated with this therapy while limiting the impact on the dialysis budget. Increasing the usage of PD to 20-25%, the levels observed in 2005-2008, will totally offset the additional costs and generate further savings.

Simplified phosphorus kinetic modeling: predicting changes in predialysis serum phosphorus concentration after altering the hemodialysis prescription.

BACKGROUND: The KDIGO work group recommends increasing dialytic phosphorus removal in Stage 5D chronic kidney disease patients with persistent hyperphosphatemia; however, optimal prescriptions to enhance phosphorus removal by hemodialysis (HD) therapies have not yet been established. This study evaluated whether phosphorus kinetic modeling based on a pseudo one-compartment model could provide practical clinical guidance for predicting changes in predialysis serum phosphorus concentration after altering the HD prescription. METHODS: Patient-specific phosphorus kinetic parameters determined from thrice weekly HD treatments on 774 patients in the HEMO Study were used to predict changes in predialysis serum phosphorus concentration after altering the HD prescription from thrice weekly to short daily and long nocturnal HD therapies. The effect of changes in the oral phosphorus binder prescription on predicted changes in the predialysis serum phosphorus concentration was also illustrated using the concept of equivalent phosphorus binder dose. RESULTS: Decreases in predialysis serum phosphorus concentration from thrice weekly HD to short daily and long nocturnal HD prescriptions demonstrated strong associations with the predialysis serum phosphorus concentration during thrice weekly HD that were relatively independent of patient-specific phosphorus kinetic parameters. Thus, the percent decrease in predialysis serum phosphorus concentration was approximately the same among patients for a given alteration in the HD prescription. Both increased weekly treatment time and frequency resulted in a reduction in the predialysis serum phosphorus concentration; however, the effect of treatment time was more influential. Simultaneous reduction in the effective phosphorus binder dose blunted the decrease in the predialysis serum phosphorus concentration. CONCLUSIONS: This study demonstrated that a simplified form of phosphorus kinetic modeling based on a pseudo one-compartment model can provide practical clinical guidance for predicting changes in predialysis serum phosphorus concentration after altering the HD prescription. Prospective validation of this approach in future studies is warranted.

Recovery time, quality of life, and mortality in hemodialysis patients: the Dialysis Outcomes and Practice Patterns Study (DOPPS).

BACKGROUND: There is limited information about the clinical and prognostic significance of patient-reported recovery time. STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: 6,040 patients in the DOPPS (Dialysis Outcomes and Practice Patterns Study). PREDICTOR: Answer to question "How long does it take you to recover from a dialysis session?" categorized as follows: fewer than 2, 2-6, 7-12, or longer than 12 hours. OUTCOMES & MEASUREMENTS: Cross-sectional and longitudinal associations between recovery time and patient characteristics, hemodialysis treatment variables, health-related quality of life (HRQoL), and hospitalization and mortality. RESULTS: 32% reported recovery time shorter than 2 hours; 41%, 2-6 hours; 17%, 7-12 hours; and 10%, longer than 12 hours. Using proportional odds (ordinal) logistic regression, shorter recovery time was associated with male sex, full-time employment, and higher serum albumin level. Longer recovery time was associated with older age, dialysis vintage, body mass index, diabetes, and psychiatric disorder. Greater intradialytic weight loss, longer dialysis session length, and lower dialysate sodium concentration were associated with longer recovery time. In facilities that used uniform dialysate sodium concentrations for ≥90% of patients, the adjusted OR of longer recovery time, comparing dialysate sodium concentration<140 vs 140 mEq/L, was 1.72 (95% CI, 1.37-2.16). Recovery time was correlated positively with symptoms of kidney failure and kidney disease burden score and inversely with HRQoL mental and physical component summary scores. Using Cox regression, adjusting for potential confounders not influenced by recovery time, it was associated positively with first hospitalization and mortality (adjusted HRs for recovery time>12 vs 2-6 hours 1.22 [95% CI, 1.09-1.37] and 1.47 [95% CI, 1.19-1.83], respectively). LIMITATIONS: Answers are subjective and not supported by physiologic measurements. CONCLUSIONS: Recovery time can be used to identify patients with poorer HRQoL and higher risks of hospitalization and mortality. Interventions to reduce recovery time and possibly improve clinical outcomes, such as increasing dialysate sodium concentration, need to be tested in randomized trials.

Economic evaluation of frequent home nocturnal hemodialysis based on a randomized controlled trial.

Provider and patient enthusiasm for frequent home nocturnal hemodialysis (FHNHD) has been renewed; however, the cost-effectiveness of this technique is unknown. We performed a cost-utility analysis of FHNHD compared with conventional hemodialysis (CvHD; 4 hours three times per week) from a health payer perspective over a lifetime horizon using patient information from the Alberta NHD randomized controlled trial. Costs, including training costs, were obtained using microcosting and administrative data (CAN$2012). We determined the incremental cost per quality-adjusted life year (QALY) gained. Robustness was assessed using scenario, sensitivity, and probabilistic sensitivity analyses. Compared with CvHD (61% in-center, 14% satellite, and 25% home dialysis), FHNHD led to incremental cost savings (-$6700) and an additional 0.38 QALYs. In sensitivity analyses, when the annual probability of technique failure with FHNHD increased from 7.6% (reference case) to ≥19%, FHNHD became unattractive (>$75,000/QALY). The cost/QALY gained became $13,000 if average training time for FHNHD increased from 3.7 to 6 weeks. In scenarios with alternate comparator modalities, FHNHD remained dominant compared with in-center CvHD; cost/QALYs gained were $18,500, $198,000, and $423,000 compared with satellite CvHD, home CvHD, and peritoneal dialysis, respectively. In summary, FHNHD is attractive compared with in-center CvHD in this cohort. However, the attractiveness of FHNHD varies by technique failure rate, training time, and dialysis modalities from which patients are drawn, and these variables should be considered when establishing FHNHD programs.

Randomized, controlled trial of glucose-sparing peritoneal dialysis in diabetic patients.

Glucose-containing peritoneal dialysis solutions may exacerbate metabolic abnormalities and increase cardiovascular risk in diabetic patients. Here, we examined whether a low-glucose regimen improves metabolic control in diabetic patients undergoing peritoneal dialysis. Eligible patients were randomly assigned in a 1:1 manner to the control group (dextrose solutions only) or to the low-glucose intervention group (IMPENDIA trial: combination of dextrose-based solution, icodextrin and amino acids; EDEN trial: a different dextrose-based solution, icodextrin and amino acids) and followed for 6 months. Combining both studies, 251 patients were allocated to control (n=127) or intervention (n=124) across 11 countries. The primary endpoint was change in glycated hemoglobin from baseline. Mean glycated hemoglobin at baseline was similar in both groups. In the intention-to-treat population, the mean glycated hemoglobin profile improved in the intervention group but remained unchanged in the control group (0.5% difference between groups; 95% confidence interval, 0.1% to 0.8%; P=0.006). Serum triglyceride, very-low-density lipoprotein, and apolipoprotein B levels also improved in the intervention group. Deaths and serious adverse events, including several related to extracellular fluid volume expansion, increased in the intervention group, however. These data suggest that a low-glucose dialysis regimen improves metabolic indices in diabetic patients receiving peritoneal dialysis but may be associated with an increased risk of extracellular fluid volume expansion. Thus, use of glucose-sparing regimens in peritoneal dialysis patients should be accompanied by close monitoring of fluid volume status.

Determinants of phosphorus mobilization during hemodialysis.

Our recent work proposed a pseudo one-compartment model for describing intradialysis and postdialysis rebound kinetics of phosphorus. In this model, phosphorus is removed directly from a central distribution volume with the rate of phosphorus mobilization from a second, very large compartment proportional to the phosphorus mobilization clearance. Here, we evaluated factors of phosphorus mobilization clearance and postdialysis central distribution volume from 774 patients in the HEMO Study. Phosphorus mobilization clearance and postdialysis central distribution volume were 87 (65, 116) ml/min, median (interquartile range), and 9.4 (7.2, 12.0) liter, respectively. The phosphorus mobilization clearance was significantly higher for male patients than for female patients. Both the phosphorus mobilization clearance and the postdialysis central distribution volume were significantly associated with postdialysis body weight but negatively with the predialysis serum phosphorus concentration. The postdialysis central distribution volume was also significantly associated with age. Overall, the postdialysis central distribution volume was 13.6% of the postdialysis body weight. Thus, the phosphorus mobilization clearance during hemodialysis is higher when predialysis serum phosphorus concentration is low and higher in male patients than in female patients. The central distribution volume of phosphorus is a space approximating the extracellular fluid volume.

Phosphorus kinetics during hemodiafiltration: analysis using a pseudo-one-compartment model.

BACKGROUND/AIMS: On-line hemodiafiltration (HDF) has been previously shown to result in modest reductions in predialysis serum phosphorus concentration compared with conventional hemodialysis (HD); however, understanding of phosphorus kinetics during these therapies remains limited. METHODS: Previously published phosphorus kinetic data during HDF and HD were analyzed using a pseudo-one-compartment kinetic model. Phosphorus mobilization clearance (KM) and dialyzer phosphorus clearance (Kd) were simultaneously estimated from measured predialysis and postdialysis serum phosphorus concentrations and total removed phosphorus during each treatment. RESULTS: KM varied among patients between 53 and 173 ml/min. Values of KM during HDF (105 ± 34, mean ± standard deviation, ml/min) and HD (112 ± 44 ml/min) were not different (p = 0.5); however, Kd during HDF (175 ± 23 ml/min) was higher (p = 0.01) than during HD (160 ± 14 ml/min). CONCLUSION: A pseudo-one-compartment kinetic model is useful for the analysis of phosphorus kinetic data during HDF. Lower predialysis serum phosphorus concentrations during HDF are likely due to increased extracorporeal phosphorus clearance.

Physiologic volume of phosphorus during hemodialysis: predictions from a pseudo one-compartment model.

The kinetics of plasma phosphorus concentrations during hemodialysis (HD) are complex and cannot be described by conventional one- or two-compartment kinetic models. It has recently been shown by others that the physiologic (or apparent distribution) volume for phosphorus (Vr-P) increases with increasing treatment time and shows a large variation among patients treated by thrice weekly and daily HD. Here, we describe the dependence of Vr-P on treatment time and predialysis plasma phosphorus concentration as predicted by a novel pseudo one-compartment model. The kinetics of plasma phosphorus during conventional and six times per week daily HD were simulated as a function of treatment time per session for various dialyzer phosphate clearances and patient-specific phosphorus mobilization clearances (K(M)). Vr-P normalized to extracellular volume from these simulations were reported and compared with previously published empirical findings. Simulated results were relatively independent of dialyzer phosphate clearance and treatment frequency. In contrast, Vr-P was strongly dependent on treatment time per session; the increase in Vr-P with treatment time was larger for higher values of K(M). Vr-P was inversely dependent on predialysis plasma phosphorus concentration. There was significant variation among predicted Vr-P values, depending largely on the value of K(M). We conclude that a pseudo one-compartment model can describe the empirical dependence of the physiologic volume of phosphorus on treatment time and predialysis plasma phosphorus concentration. Further, the variation in physiologic volume of phosphorus among HD patients is largely due to differences in patient-specific phosphorus mobilization clearance.

Steady state phosphorus mass balance model during hemodialysis based on a pseudo one-compartment kinetic model.

PURPOSE: Mathematical models of phosphorus kinetics and mass balance during hemodialysis are in early development. We describe a theoretical phosphorus steady state mass balance model during hemodialysis based on a novel pseudo one-compartment kinetic model. METHODS: The steady state mass balance model accounted for net intestinal absorption of phosphorus and phosphorus removal by both dialysis and residual kidney function. Analytical mathematical solutions were derived to describe time-dependent intradialytic and interdialytic serum phosphorus concentrations assuming hemodialysis treatments were performed symmetrically throughout a week. RESULTS: Results from the steady state phosphorus mass balance model are described for thrice weekly hemodialysis treatment prescriptions only. The analysis predicts 1) a minimal impact of dialyzer phosphorus clearance on predialysis serum phosphorus concentration using modern, conventional hemodialysis technology, 2) variability in the postdialysis-to-predialysis phosphorus concentration ratio due to differences in patient-specific phosphorus mobilization, and 3) the importance of treatment time in determining the predialysis serum phosphorus concentration. CONCLUSIONS: We conclude that a steady state phosphorus mass balance model can be developed based on a pseudo one-compartment kinetic model and that predictions from this model are consistent with previous clinical observations. The predictions from this mass balance model are theoretical and hypothesis-generating only; additional prospective clinical studies will be required for model confirmation.

The impact of nocturnal hemodialysis on sexual function.

BACKGROUND: Sexual dysfunction is common in patients with end stage renal disease (ESRD) and treatment options are limited. Observational studies suggest that nocturnal hemodialysis may improve sexual function. We compared sexual activity and responses to sexual related questions in the Kidney Disease Quality of Life Short Form questionnaire among patients randomized to frequent nocturnal or thrice weekly conventional hemodialysis. METHODS: We performed a secondary analysis of data from an RCT which enrolled 51 patients comparing frequent nocturnal and conventional thrice weekly hemodialysis. Sexual activity and responses to sexual related questions were assessed at baseline and six months using relevant questions from the Kidney Disease Quality of Life Short Form questionnaire. RESULTS: Overall, there was no difference in sexual activity, or the extent to which people were bothered by the impact of kidney disease on their sex life between the two groups between randomization and 6 months. However, women and patients age < 60 who were randomized to frequent nocturnal hemodialysis were less bothered by the impact of kidney disease on their sex life at 6 months, compared with patients allocated to conventional hemodialysis (p = 0.005 and p = 0.024 respectively). CONCLUSIONS: Our results suggest that frequent nocturnal hemodialysis is not associated with an improvement in sexual activity in all patients but might have an effect on the burden of kidney disease on sex life in women and patients less than 60 years of age. The validity of these subgroup findings require confirmation in future RCTs.

A cluster randomized trial of an enhanced eGFR prompt in chronic kidney disease.

BACKGROUND AND OBJECTIVES: Despite reporting estimated GFR (eGFR), use of evidence-based interventions in CKD remains suboptimal. This study sought to determine the effect of an enhanced eGFR laboratory prompt containing specific management recommendations, compared with standard eGFR reporting in CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A cluster randomized trial of a standard or enhanced eGFR laboratory prompt was performed in 93 primary care practices in Alberta, Canada. Although all adult patients with CKD (eGFR <60 ml/min per 1.73 m(2)) were included, medication data were only available for elderly patients (aged ≥66 years). The primary outcome, the proportion of patients with diabetes or proteinuria receiving an angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB), was assessed in elderly CKD patients. RESULTS: There were 5444 elderly CKD patients with diabetes or proteinuria who were eligible for primary outcome assessment, irrespective of baseline ACEi/ARB use. ACEi/ARB use in the subsequent year was 77.1% and 76.9% in the standard and enhanced prompt groups, respectively. In the subgroup of elderly patients with an eGFR <30 ml/min per 1.73 m(2), ACEi/ARB use was higher in the enhanced prompt group. Among 22,092 CKD patients, there was no difference in the likelihood of a composite clinical outcome (death, ESRD, doubling of serum creatinine, or hospitalization for myocardial infarction, heart failure, or stroke) over a median of 2.1 years. CONCLUSIONS: In elderly patients with CKD and an indication for ACEi/ARB, an enhanced laboratory prompt did not increase use of these medications.

The impact of short daily and nocturnal hemodialysis on quality of life, cardiovascular risk and survival.

End-stage renal disease (ESRD) is a significant global health problem that places a considerable burden on health care resources. The leading cause of death in ESRD patients is cardiovascular disease, which is often preceded by changes in cardiac geometry, including left ventricular hypertrophy (LVH). Treatments that result in regression of LVH have been shown to lead to better clinical outcomes. Globally, most ESRD patients receive conventional hemodialysis (CHD) 3 times per week, but mortality rates remain high and quality of life (QoL) is poor. Increasing the frequency of HD to 5 or 6 times per week, either as short daily HD (SDHD) or nocturnal HD (NHD), can improve QoL, reduce cardiovascular risk and prolong survival, compared with CHD. Improvements in these end points are likely driven by enhancements in fluid management, blood pressure control, mineral metabolism and left ventricular mass regression. From a practical standpoint, SDHD and NHD are best delivered at home. Barriers to adoption of home HD are chiefly modifiable, and may include lack of a care partner or family support, fear of cannulation and access disconnection, and uncertainty in one's ability to learn the procedures required to perform self-HD. On a positive note, substantial progress has been made to overcome these and other perceived barriers.