For those patients with CKD followed in a pre-dialysis environment, it is well appreciated that modality education leads to an informed decision regarding type of dialysis selected. However, for those individuals starting dialysis acutely and requiring chronic renal replacement therapy, modality education may be lacking. Because of the acuity of the dialysis start, and the intercurrent illness or event which precipitated and acute start, these patients require a specialized approach to education, and indeed, require a combination of education and support to learn about and choose a renal replacement therapy. The University Health Network, in Toronto, Canada, has developed a program and approach to education and support of this group of patients. The approach, results, and theoretical underpinnings of this program are reviewed, and a potential new "hybrid" educational framework is proposed.
In August 1995, the Ontario Ministry of Health (MOH) issued a request for proposal (RFP) for the establishment of new and expanded dialysis services. London Health Sciences Centre (LHSC) was successful in expanding its integrated dialysis delivery network with satellites in Stratford, Woodstock and Owen Sound. This achievement required collaboration of LHSC and host hospital staff to meet the challenging RFP requirements. With final approval received in January 1997, efforts were required to establish an operational model supporting self-care and full-care patients, to train satellite staff and patients, and to manage the resulting clinical impact. A balanced scorecard (Kaplan & Norton, 1992) evaluation model was developed. Initial outcome data indicate that full-care patients in satellites require more fallback support to London units, experience more hypotensive episodes during dialysis and, in some cases, demonstrate lower levels of dialysis adequacy and nutritional status when compared to satellite self-care patients. Findings from these data will assist in revising patient inclusion criteria and processes to optimize community-based dialysis.
To determine the opinions and attitudes of Canadian nephrologists about dialysis modality decisions and optimal dialysis system design.
Members of the Canadian Society of Nephrology.
A mailed survey questionnaire.
A 66% response rate was obtained. Decisions about modality are reported to be based most strongly on patient preference (4.4 on a scale from 1 to 5), followed by quality of life (4.06), morbidity (3.97), mortality (3.85), and rehabilitation (3.69), while neither facility (1.78) nor physician (1.62) reimbursement are important. When asked about the current relative utilization of each modality, nephrologists felt that hospital-based hemodialysis (HD) is slightly overutilized (2.53), continuous ambulatory peritoneal dialysis (CAPD) is about right (3.00), while cycler peritoneal dialysis (PD) (3.53), community-based full (3.83) and self-care HD (3.91), and home HD (4.02) are underutilized. A hypothetical question about optimal distribution to maximize survival revealed that a type of HD should constitute 62.8% of the mix, with more emphasis on cycler PD (14.9%), community-based full care HD (13.8%), self-care HD (14.5%), and home HD (9.0%) than is current practice. However, when the goal was to maximize cost effectiveness, HD fell slightly to 57.8%.
These survey results suggest that the current national average 66%/34% HD/PD ratio is reasonable. However, there appears to be a consensus that Canada could evolve to a more cost-effective, community-based dialysis system without compromising patient outcomes.
Although evidence supporting the advantages of multidisciplinary team-based chronic kidney disease (CKD) care is not well developed, many groups are advocating increased availability of this model.
The research design is a mailed survey sent to 523 members of the Canadian and Quebec Societies of Nephrology.
After excluding 113 respondents who declared themselves to be ineligible, the response rate was 54%. Ninety-one percent of nephrologists reported that they usually or always use a CKD clinic. Decisions about when to perform CKD-related tasks were based mainly on an estimate of glomerular filtration rate, rather than time remaining before end-stage renal disease (ESRD). The ideal creatinine clearance for referral to a CKD clinic was 30 to 59 mL/min (0.50 to 0.98 mL/s), but the usual level was 20 to 29 mL/min (0.33 to 0.44 mL/s). The ideal time for referral was more than 12 months before ESRD. Renal replacement therapy discussions were initiated at a creatinine clearance of 20 to 29 mL/min (57%). Nephrologists supported promotion of home dialysis for suitable patients, but not mandating this. Nephrologists did not provide a blunt prognosis to patients who did not specifically ask. Late referral based on adequate time for ESRD preparation was reported to be 4 to 6 months (27%), 7 to 9 months (26%), or 10 to 12 months (30%). Thirty-eight percent said that optimal preparation takes 13 months or longer.
The literature's common definition of less than 3 months as a cutoff value between late and early referral is not endorsed. Given that multidisciplinary team-based care is widely available in Canada, this study might inform other jurisdictions about the merits and problems associated with multidisciplinary team-based care and might shape the agenda for future empirical research.
Morbidity and mortality associated with chronic kidney disease (CKD) is higher than that of the normal population, and the incidence of end-stage renal disease (ESRD) continues to increase. Several factors contribute to the uncoordinated and suboptimal management of CKD, including the attitude and behaviour of nephrologists, referring physicians and patients, and economic constraints on healthcare systems. Late referral of at-risk patients to specialist care is an area of particular concern, as this denies nephrologists adequate opportunity to prevent progression of CKD and associated complications such as anaemia. Due to the ageing population and advances in technology, the costs of treating CKD and ESRD continue to escalate and represent another barrier to the delivery of optimal care. Optimizing the care provided to CKD patients requires a coordinated approach to the management of the condition. Closer collaboration and improved communication across specialities is important for the timely referral of patients and for efficient utilization of available resources. A multidisciplinary approach may facilitate patient identification and improve the management of CKD.
During the past few decades the pattern of end-stage renal failure disease has changed with increasing number of elderly patients admitted for dialysis. In spite of their increasing number, little is known about the optimal mode of therapy of the 'old old' (those >or=80 years) patients.
In this retrospective study, we analysed the results of treatment of 31 non-institutionalized 'old old' patients at Toronto Western Hospital (17) and Scarborough General Hospital (14) and seven institutionalized patients in chronic care, Riverdale Hospital. The patients were on CAPD with Twin-bag Baxter (28) or Home Choice, Baxter or Fresenius CCPD system (10). Patients were screened at the CAPD clinic when routine blood investigations were done. Patient and technique survival, initial and final laboratory data (last visit or before death) and complications related/unrelated to dialysis method are presented.
Multiple comorbid conditions were present at the start of the treatment and new added during treatment; very few were dialysis-related. The majority of non-institutionalized patients required assistance of home-care nurse to perform dialysis. Peritonitis (1/28.6 patient months) and exit-site infection rate (1/75.1 patient months) were low and responded to treatment. Incidence of peritonitis was higher among institutionalized debilitated patients (1/5.3 patient months). Incidence of hospitalization was 1/14.7 patient months and patients spent in hospital 7.5 days/patient year. Forty-seven per cent of patients survived 24 months; 39% survived 30 months. Technique survival was 91.5% at 12 months and 81.4% at 30 months. Poor appetite and malnutrition were frequent among very old patients. Patients and their families were motivated for treatment and discontinuation of dialysis was not higher than described elsewhere in literature.
This study has demonstrated that chronic peritoneal dialysis could be recommended as a safe and suitable modality of treatment of end-stage renal failure in old old patients.
382 Brescia-Cimino type arteriovenous fistulae were created for chronic haemodialysis. Success rate at the first attempt was 73.6% of 281 cases. The most common method of anastomosis was endtoside vein to artery type. Thrombosis was the most frequent complication, other miscellaneous complications were less common.