Is health-related quality of life trajectory associated with dialysis modality choice in advanced chronic kidney disease?

BACKGROUND: Patients with advanced chronic kidney disease have lower health-related quality of life (HRQOL) than the general population. There is uncertainty regarding patterns of HRQOL changes before dialysis initiation. This study aimed to characterise HRQOL trajectory and assess its potential association with intended dialysis modality. METHODS: This prospective single-centre cohort study followed adults with an estimated glomerular filtration rate ≤15 mL/min/1.73 m2 for one year. Patients were allocated into one of two groups based on their intended treatment modality, 'home dialysis' (peritoneal dialysis or home haemodialysis (HD)) and 'other' (in-centre HD or conservative care). Follow-up was for up to 1 year or earlier if initiated on kidney replacement therapy or died. Kidney Disease Quality of Life - Short Form (KDQOL-SF) was completed every 6 months. Predictors of changes in KDQOL-SF components were modelled using mixed effect multivariable linear regressions. RESULTS: One hundred and nine patients were included. At baseline, crude physical composite summary (PCS) (45 ± 10 vs. 39 ± 8) was higher in patients choosing home dialysis (n = 41), while mental composite summary (MCS) was similar in both groups. After adjustment, patients choosing home dialysis had an increase in MCS (B = 8.4 per year, p = 0.007) compared to those selecting in-centre HD/conservative care. This translates into an annual increase in MSC by 3 points for the 'home dialysis' group, compared to an annual decline by 5.4 points in the 'other' group. There was no difference in PCS trajectory through time. CONCLUSIONS: Patients choosing home dialysis had improved MCS over time compared to those not selecting home dialysis. More work is needed to determine how differences in processes of care and/or unmeasured patient characteristics modulate this association.

Optimization of Dialysis Modality Transitions for Improved Patient Care.

PURPOSE OF REVIEW: Initial and subsequent modality decisions are important, impacting both clinical outcomes and quality of life. Transition from chronic kidney disease to dialysis and between dialysis modalities are periods were patients may be especially vulnerable. Reviewing our current knowledge surrounding these critical periods and identifying areas for future research may allow us to develop dialysis strategies beneficial to patients. SOURCES OF INFORMATION: We searched the electronic database PubMed and queried Google Scholar for English peer-reviewed articles using appropriate keywords (non-exhaustive list): dialysis transitions, peritoneal dialysis, home hemodialysis, integrated care pathway, and health-related quality of life. Primary sources were accessed whenever possible. METHODS: In this narrative review, we aim to expose the controversies surrounding home-dialysis first strategies and examine the evidence underpinning home-dialysis first strategies as well as home-to-home and home-to-in-center transitions. KEY FINDINGS: Diverse factors must be taken into consideration when choosing initial and subsequent dialysis modalities. Given the limitations of available data (and lack of convincing benefit or detriment of one modality over the other), patient-centered considerations may prime over suspected mortality benefits of one modality or another. LIMITATIONS: Available data stem almost exclusively from retrospective and observational studies, often using large national and international databases, susceptible to bias. Furthermore, this is a narrative review which takes into account the views and opinions of the authors, especially as it pertains to optimal dialysis pathways. IMPLICATIONS: Emphasis must be placed on individual patient goals and preferences during modality selection while planning ahead to achieve timely and appropriate transitions limiting discomfort and anxiety for patients. Further research is required to ascertain specific interventions which may be beneficial to patients.

CONTEXTE MOTIVANT LA REVUE: Les décisions entourant le choix de la modalité de dialyse initiale et subséquente sont importantes puisqu'elles ont des répercussions sur les résultats cliniques et la qualité de vie du patient. La transition entre la période l'insuffisance rénale chronique et l'amorce de la dialyse, de même que les périodes de transition entre différentes modalités de dialyse sont des moments où les patients sont particulièrement vulnérables. L'évaluation des données probantes entourant ces périodes et la définition de futurs axes de recherche pourraient contribuer à l'optimisation des soins aux patients. SOURCES: Nous avons identifié dans PubMed et Google Scholar les articles révisés par les pairs et rédigés en anglais répondant aux mots-clés appropriés (liste non exhaustive): dialysis transitions (transitions en dialyse), peritoneal dialysis (dialyse péritonéale), home hemodialysis (hémodialyse à domicile), integrated care pathway (schéma de soins intégrés), et health-related quality of life (qualité de vie liée à l'état de santé). Dans la mesure du possible, les sources principales ont été consultées. MÉTHODOLOGIE: Dans notre revue narrative, nous souhaitons exposer les controverses entourant les stratégies initiales de dialyse à domicile et examiner les données probantes qui sous-tendent les stratégies de dialyse à domicile d'abord, mais également les transitions « de domicile à domicile ¼ et « de domicile à centre ¼. PRINCIPAUX RÉSULTATS: Plusieurs facteurs sont à considérer au moment de choisir les modalités de dialyse initiale et subséquente. Compte tenu des limites imposées par le manque de données disponibles (et de l'absence d'arguments convaincants quant aux avantages ou désavantages d'une modalité par rapport à une autre), les facteurs axés sur les patients sont susceptibles de l'emporter sur les avantages présumés de l'une ou l'autre modalité sur le taux de mortalité. LIMITES: Les données disponibles proviennent presque exclusivement d'études rétrospectives et observationnelles, lesquelles ayant souvent eu recours aux vastes bases de données nationales et internationales, et sont donc sujettes à l'introduction de biais. En outre, il s'agit d'une revue narrative qui tient compte du point de vue des auteurs, particulièrement en regard des schémas de dialyse optimaux. CONCLUSION: Au moment de choisir la modalité de dialyse, il importe d'accorder une importance aux objectifs et préférences du patient, tout en planifiant la réalisation de transitions opportunes et appropriées, afin de limiter l'inconfort et l'anxiété du patient. D'autres études sont nécessaires pour définir les interventions susceptibles de bénéficier aux patients.

Single-Pill Combinations in the Treatment of Hypertension in Adults: Beyond Convenience.

Adequate blood pressure control in patients with hypertension remains the pillar of cardiovascular-event prevention. Smoking cessation, reduced dietary salt intake, physical exercise and weight loss contribute to better blood pressure control and reduced cardiovascular morbidity, but alone, they are often insufficient in doing so, and their success is highly dependent on individual patient motivation. Pharmacologic therapy, thus, remains necessary for most patients, and our conception of the optimal way of approaching this therapy has evolved over the past decade. Traditionally, monotherapy using a first-line drug was initiated and uptitrated, with the addition of other antihypertensive agents as needed. The latest Hypertension Canada guidelines, however, now recommend first-line treatment with single-pill combinations in patients without compelling indications for treatment. In this review, we discuss the evidence behind this recommendation and how single-pill combinations can improve patient care.