ABSTRACT
INTRODUCTION: Inadequate predialysis care and education impacts the selection of a dialysis modality and is associated with adverse clinical outcomes. Transitional care units (TCUs) aim to meet the unmet educational needs of incident dialysis patients, but their impact beyond increasing home dialysis utilization has been incompletely characterized. METHODS: This retrospective study included adults initiating in-center hemodialysis at a TCU, matched to controls (1:4) with no TCU history initiating in-center hemodialysis. Patients were followed for up to 14 months. TCUs are dedicated spaces where staff provide personalized education and as-needed adjustments to dialysis prescriptions. For many patients, therapy was initiated with four to five weekly dialysis sessions, with at least some sessions delivered by home dialysis machines. Outcomes included survival, first hospitalization, transplant waiting-list status, post-TCU dialysis modality, and vascular access type. FINDINGS: The study included 724 patients initiating dialysis across 48 TCUs, with 2892 well-matched controls. At the end of 14 months, patients initiating dialysis in a TCU were significantly more likely to be referred and/or wait-listed for a kidney transplant than controls (57% vs. 42%; p < 0.0001). Initiation of dialysis at a TCU was also associated with significantly lower rates of receiving in-center hemodialysis at 14 months (74% vs. 90%; p < 0.0001) and higher rates of arteriovenous access (70% vs. 63%; p = 0.003). Although not statistically significant, TCU patients were more likely to survive and less likely to be hospitalized during follow-up than controls. DISCUSSION: Although TCUs are sometimes viewed as only a means for enhancing utilization of home dialysis, patients attending TCUs exhibited more favorable outcomes across all endpoints. In addition to being 2.5-fold more likely to receive home dialysis, TCU patients were 42% more likely to be referred for transplantation. Our results support expanding utilization of TCUs for patients with inadequate predialysis support.
Subject(s)
Kidney Failure, Chronic , Transitional Care , Adult , Humans , Renal Dialysis/methods , Propensity Score , Retrospective Studies , Hemodialysis, Home , Kidney Failure, Chronic/therapySubject(s)
Choice Behavior , Health Services Accessibility/organization & administration , Hemodialysis, Home , Patient Participation , Cost of Illness , Health Policy , Hemodialysis, Home/psychology , Hemodialysis, Home/statistics & numerical data , Humans , Life Style , Medicare/organization & administration , Organizational Innovation , Patient Participation/psychology , Patient Participation/statistics & numerical data , Patient Selection , Politics , Reimbursement Mechanisms/organization & administration , United StatesABSTRACT
Given the results of recent randomized controlled trials as well as staffing and budget challenges that today face many institutions across North America, a novel therapeutic approach is likely necessary to enable improvements in clinical outcomes for renal failure patients. The NxStage System One was developed to address these challenges. The system is an innovative, flexible device that delivers hemodialysis, hemofiltration, and/or ultrafiltration therapies to patients with renal failure or fluid overload. The unique characteristics of this system include a highly automated system design with a drop-in cartridge to facilitate training and simple operation; portable size and independence from dedicated infrastructure to minimize practical barriers to where therapy may be administered; use of high-quality premixed treatment fluids to enable capture of the potential clinical benefits of fluid purity without the hassles of local water treatment; and wide operating ranges to allow clinician flexibility in patient therapy prescriptions. In both the chronic and acute care environments, the System One presents clinicians with a new platform for delivering patient therapy improvements within real-world constraints.
Subject(s)
Renal Dialysis/instrumentation , Equipment Design , Equipment Safety , Humans , Patient Satisfaction , User-Computer InterfaceABSTRACT
Increasing attention is being paid to quantifying the dose of dialysis prescribed and delivered to critically ill patients with acute renal failure (ARF). Recent trials in both the intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) realms have suggested that a direct relationship between dose and survival exists for both of these therapies. The purpose of this review, first, is to analyze critically the above-mentioned dose/outcome studies in acute dialysis. Subsequently, the factors influencing dose prescription and delivery are discussed, with the focus on continuous venovenous hemofiltration (CVVH). Specifically, differences between postdilution and predilution CVVH will be highlighted, and the importance of blood flow rate in dose delivery for these therapies will be discussed.
