Perceptions of multidisciplinary renal team members towards home dialysis therapies

Background: Patients with end stage kidney disease are encouraged to pursue home dialysis therapy with the aims of improving quality of life, increasing patient autonomy and reducing cost to health care systems. In a multidisciplinary team setting, patients interact with nephrologists, nurses and allied health staff, all of whom may influence a patient's modality choice. Our objective was to evaluate the perceptions of all renal team members towards home dialysis therapies. Methods: Cross-sectional survey of multidisciplinary renal team members across five renal programs in British Columbia, Canada. The survey contained questions regarding primary work area, modality preference, patient and system factors that may influence modality candidacy, perceived knowledge of home therapies and need for further education. Results: A total of 334 respondents (22 nephrologists, 172 hemodialysis nurses, 49 home nurses, 20 pre-dialysis nurses, and 71 allied health) were included (48% response rate). All respondents felt that home dialysis was beneficial for patients who work or study, improved patients' quality of life, and provided cost-savings to the system. Compared to in-center hemodialysis nurses, home therapies nurses were between 5 and 9 times more likely to favor a home therapy for patients of older age, lower socioeconomic status, lower educational level, higher burden of comorbidities and those lacking social supports. Nephrologists and patients were felt to have the most impact on modality choice, while dialysis nurses were seen as having the least impact on modality choice. Most respondents felt the need for further education in home therapies. Conclusions: The majority of multidisciplinary team members, including allied health staff, acknowledged the benefits of home therapies. There were significant discrepancies amongst team members regarding patient/system-level factors that may impact home therapies candidacy. Structured, focused and repeated education sessions for all renal team members may help to address misperceptions around factors that influence modality candidacy.

Current role of ultrasound in hemodialysis access evaluation

Physical examination (PE) is considered the backbone before vascular access (VA) placement, during maturation period and for follow-up. However, it may be inadequate in identifying suitable vasculature, mainly in comorbid patients, or in detecting complications. This review highlights the advantages of ultrasound imaging to manage VA before placement, during maturation and follow-up. Furthermore, it analyses the future perspectives in evaluating early and late VA complications thank to the availability of multiparametric platforms, point of care of ultrasound, and portable/wireless systems. Technical improvements and low-cost systems should favor the widespread ultrasound-based VA surveillance programs. This significant turning point needs an adequate training of nephrologists and dialysis nurses and the standardization of exams, parameters, and procedures.

MO524CALCIMIMETIC ADHERENCE AND PREFERENCE IN THE MANAGEMENT OF SECONDARY HYPERPARATHYROIDISM IN EUROPE: A PILOT STUDY

Background and Aims Oral cinacalcet (CIN) and IV-administered etelcalcetide (ETEL) are calcimimetics available for the management of secondary hyperparathyroidism (SHPT) in hemodialysis (HD) patients. This pilot study assessed patient adherence to calcimimetic therapy and calcimimetic preference of nephrologists and nurses based on adapted questionnaires. Method A cross-sectional survey was conducted with HD patients currently using a calcimimetic, and nephrologists and dialysis nurses who prescribed/administered calcimimetic in 7 European countries (Belgium, France, Germany, Italy, Spain, Sweden and the United Kingdom). Patient questionnaires were adapted from the Medication Adherence Report Scale (MARS), the Beliefs about Medicines Questionnaire (BMQ-specific Necessity and Concern), and Treatment Intrusiveness Scale (TIS) to understand patterns of adherence and perceptions of medications; questions about gastrointestinal (GI) symptoms were included. Questionnaires for nephrologists and nurses were adapted from the Treatment Rating Scale (TRS), Health Professional Preference Scale (HPPS), and Prescribing Comparator Scale (PCS) to understand calcimimetic preference. Questionnaires were translated and administered in the local language. Results Sixty HD patients (33 CIN and 27 ETEL), 16 nephrologists and 18 dialysis nurses participated in the survey. ETEL patients were younger than CIN patients (mean age: 57 vs. 59 yrs). ETEL patients also had a lower pill burden (mean no. of pills: 6 vs. 11) and had numerically fewer hospitalizations in the last 6 months (mean no. of days: 1.5 vs 3.9) than CIN patients. Self-reported adherence to CIN was high (mean MARS: 4.7±0.7). ETEL and CIN patients did not perceive medications (excluding dialysis, diet and dietary restrictions) as interfering with their life (mean TIS: 1.5±0.5 vs. 1.6±1.6) and neither calcimimetic group had a specific belief in medicines in terms of necessity (mean BMQ CIN: 2.4±0.6 and ETEL: 2.3±0.4) or concerns about potential side-effects (mean BMQ CIN: 3.1±0.6 and ETEL: 3.5±0.7). ETEL patients were less likely than CIN patients to experience GI symptoms in the prior month: nausea (11% vs. 49%), vomiting (11% vs. 24%), and diarrhea (15% vs. 33%). Overall, the adapted patient questionnaires showed good internal consistency for MARS (Cronbach’s α=0.99) and BMQ-Necessity and BMQ-Concerns scales (CIN: α=0.74 and ETEL: α=0.81) but lower consistency for TIS (α=0.3 for both CIN and ETEL). Nephrologists and nurses had been practicing for a mean of 17 yrs. Nephrologists and nurses viewed ETEL to have more efficacy, lower risk of side effects, lower risk of non-adherence, lower burden for patients compared to CIN according to the TRS. According to HPPS, the top 3 treatment attributes for ETEL preference vs. CIN among nephrologists were encouraging patient adherence (93%; n=14/15), minimizing patient burden (87%; n=13/15) and having fewer side effects (80%; 12/15). Similar for nurses, encouraging patient adherence (88%; n=15/17) and minimizing patient burden (94%; n=16/17) were top attributes for ETEL preference as well as improving patient quality of life (82%; 14/17). Based on PCS, the majority of nephrologists agreed that compared to CIN, ETEL will ensure high adherence (100%), achieve better PTH control (93%; 14/15), reduce treatment burden for patients (87%; 13/15), improve patient’s quality of life (80%; 12/15), and improve effectiveness without increasing side-effects (80%; 12/15); they also agreed that ETEL created more work for nursing staff (80%; 12/15). Two thirds of nephrologists (n=10/15) agreed that ETEL would be more efficacious than CIN. Conclusion In this pilot study, CIN patients self-reported high adherence and both calcimimetic groups did not perceive medications to be concerning or intrusive. Nephrologists and nurses showed preference for ETEL than CIN. The questionnaires were validated and will be administered in a large study.

Arteriovenous Fistula Creation for Hemodialysis: Evaluation of Complications

Background: Vascular access care is a classic example of multidisciplinary team work among nephrologists, vascular surgeons, duplex specialists, dialysis nurses and dialysis staff. The objectives of this study were to determine the complication of arteriovenous fistula (AVF) for hemodialysis (HD) and to find out the role of duplex study for the management of fistula complications. Methods: This was a prospective type of study done on 121 arteriovenous fistulas. All operations were done in different hospitals in Dhaka city. After duplex study of upper limb vessels, the site of fistula creation was determined. All Radio-cephalic, ulnar-basilic and brachiocephalic fistulas were done under local anesthesia. Other fistula of the series was done under brachial block. Immediate postoperative bruit, thrill and distal pulses were monitored. Fistulas were considered mature after at least 6 weeks of fistula creation with good visualization of arterialized vein and good thrill. Patients were advised to report if any complication arises. Results: The most common fistula was Radio-cephalic fistulas (72.73%) and then Brachio-cephalic fistulas (19.84%). The left upper limb was the first choice for fistula creation as a non-dominant limb. Most fistula was created in left upper limb (76.86%). The most common complication was stenosis of arterialized veins (4.13%) and another type of stenosis was found at anastomotic site (2.48%). Second most common complication was cannulation site infections (3.31%). Another common type of infection was found at the site of fistula creation (2.48%). Thrombosis, aneurysm and pseudoaneurysm were identified as the most detrimental complications. Conclusion: Arteriovenous fistula is an important issue for hemodialysis patient as the life line. Dialysis nurses and technician should have knowledge about antisepsis and potential complication of AVFs. Early diagnosis and early treatment prevent loss of vascular access and reduce serious morbidity and mortality. Both the patients and dialysis staffs should give highest care for the AVF to reduce the complications. Bangladesh Heart Journal 2020; 35(2) : 100-105

Ultrasound mapping of new cannulation sites for arteriovenous fistulas/grafts at South Tyneside and Sunderland NHS Foundation Trust (STSFT) Renal Unit.

The cannulation of vascular access specially becomes difficult in elderly, diabetic and obese hemodialysis patients. The accessibility of an AV fistula largely relies on the condition of the patient’s veins, which often leads to difficulty in cannulation with the traditional blind method. South Tyneside and Sunderland NHS Foundation Trust (STSFT) Renal unit adopted ultrasound mapping of new cannulation sites for arteriovenous fistulas and arteriovenous grafts. The aim of this study was to evaluate the qualitative impact of this practice on the dialysis patients. This was a qualitative study and was conducted in the Renal Unit at STSFT. Haemodialysis patients with deep or small vessels for cannulation, a vessel with problems and a vessel whose cannulation on the first attempt was vital were included in the study. AVF/AVG were mapped using Doppler ultrasound (US) undertaken by a consultant Interventional Nephrologist (IN). The map of the AVF/AVG and new cannulation sites were captured as an image on the patients’ smart phone to act as record to show the dialysis nurse cannulating the AVF/AVG. It was hoped that this would encourage rope laddering and AVF/AVG preservation. Patients reported no significant improvement in cannulation process even after US mapping of new cannulation sites. Patients did report a better understanding of the AVF/AVG geometry especially amongst the self cannulators on home haemodialysis. According to the patients the successful cannulation was mainly dependent on the skills of dialysis nurses rather than the US mapping of the AVF/AVG being of any assistance.

Peritoneal Dialysis Failure and its Impact on Holistic Kidney Care: A Case Report

Introduction Peritonitis remains the primary cause of treatment failure among patients with end-stage kidney disease on continuous ambulatory peritoneal dialysis. However, detailed case analyses illustrating the application of current research in clinical practice remain scant. This case report aimed to elucidate the roles of dialysis nurses in a hospital setting in the management of a 62-year-old male patient with a history of kidney failure secondary to amyloidosis. Case Presentation The patient was diagnosed with continuous ambulatory peritoneal dialysis-associated peritonitis. Management and Outcomes Dialysis nurses applied evidence-based practices in the management of the patient’s exit-site infection, imbalanced nutrition, and psychosocial concerns. The patient was discharged after 7 days, with a comprehensive treatment regimen, including an individualized peritoneal dialysis protocol adjusted to his daily schedules, education on self-care techniques, and continual nutritional management to prevent recurrence and improve his overall health. This case report shows that admissions for continuous ambulatory peritoneal dialysis-associated peritonitis require evidence-based nursing interventions specific to, and geared toward, each patient’s prioritized health problems. Discussion Peritonitis cases are preventable with appropriate nursing interventions that can lower the chance of treatment failure and long-term impact caused by an abrupt switch to hemodialysis. To successfully manage patients with continuous ambulatory peritoneal dialysis-associated peritonitis, dialysis nurses should appreciate the intricacies of the analyses underpinning their professional practices in promoting the patient’s self-care techniques.

The Improvement of Working Posture and Ergonomic Workplace Stretching Decreased Musculoskeletal Complaint and Fatigue and Increased Productivity of Nurses

General fatigue complaints and musculoskeletal disorders are two of the most common symptoms experienced by dialysis nurses, as the products of the poor ergonomic working poses. Ergonomic intervention and stretching in the workplace are needed to reduce the symptoms. Unnatural pose has a potential to develop general fatigue and musculoskeletal disorders in hemodialysis room where each nurse in every shift is in charge to take care of four patients. The study aims to investigate the improvement of poses of work ergonomically by using ergonomic workplace stretching to reduce complaints in musculoskeletal and general fatigue which in turn can expectedly improve work productivity in hemodialysis room. This study is an experimental study with treatment by subject design. The study was conducted in hemodialysis unit in Wangaya Regional Public Hospital (WRPH) Denpasar from October until December 2019 with 11 people as the participants. As the result, there is no significant difference in the average of musculoskeletal complaints before working with p=0.350 (p>0.05). Meanwhile, the average of musculoskeletal complaints of nurse after working shows a significant difference that is p=0.001 (p<0.05). The analysis result indicates that there is a significant decrease in musculoskeletal complaints, which is 36.18%. The average of general fatigue before working shows no significant difference in score, that is p=0.350 (p>0.05). In the other side, there is a significant difference in score after working with p=0.001 (p<0.05). The analysis result reveals that there is a significant decrease in general fatigue for 66.97%. A significant improvement is shown in the productivity average with p=0.001 (p<0.05). The conclusion of this study is the improvement in poses of work and ergonomic workplace stretching have reduced the complaints in musculoskeletal and general fatigue and also improve nurses’ working productivity in hemodialysis unit.