Lori Harwood

Optimal timing of initiation of chronic hemodialysis

Despite the availability of clinical guidelines for the timing of dialysis initiation in both the United States and Canada, patients continue to start dialysis at very low levels of predicted glomerular filtration rate (GFR). A cross‐sectional study was performed to determine the demographic and clinical characteristics of patients who started hemodialysis, their level of GFR, and mortality at 1 and 2 years following the initiation of dialysis. Retrospective data were collected on all eligible patients who commenced chronic hemodialysis in 1 tertiary care center in Canada from March 2001 to February 2005. Only those patients who had been followed by a nephrologist in the chronic kidney disease clinic before dialysis initiation were included (n=271). Seventeen percent of patients started hemodialysis late (GFR<5 mL/min/1.73 m2). Compared with the group of patients who started dialysis earlier, the late start group were significantly younger (p=0.008), had more females (p=0.013), more employed (p=0.051), less cardiac (p<0.001), and peripheral vascular disease (p=0.031), and were taking medication for hypertension (p=0.041). Serum albumin was lower in the late start group (p=0.023). At year 1, there was no difference in mortality rate while at year 2, the earlier the dialysis, the greater the mortality rate (p=0.022). After adjustment for demographic variables and comorbidities, only antihypertensive use had an independent but weak association with the 2 year mortality. Adjustment for all these variables eliminated the significant association noted for the 2 year mortality in the early versus late dialysis start. The survival benefit for late versus early dialysis start appears to be multifactorial and relates to a preponderance of clinical and demographic factors favoring a lengthened survival occurring in the late dialysis group. Our survival benefit findings suggest the premorbid health condition is a more important determinant of 2 year survival than the timing of dialysis initiation.

Canadian Society of Nephrology Commentary on the 2012 KDIGO Clinical Practice Guideline for Anemia in CKD

The KDIGO (Kidney Disease: Improving Global Outcomes) 2012 clinical practice guideline for anemia management in patients with chronic kidney disease provides the structural and evidence base for the Canadian Society of Nephrology commentary on this guidelines relevancy and application to the Canadian health care system. While in general agreement, we provide commentary on 11 of the 61 KDIGO guideline statements. Specifically, we agreed that a therapeutic trial of iron is appropriate in cases in which a reduction in erythropoiesis-stimulating agent (ESA) dosage or avoidance of ESA and transfusion is desired, transferrin saturations are >30%, and ferritin concentrations are >500 μg/L. However, we concluded that there is insufficient evidence to support an upper target or threshold for ferritin and transferrin saturation levels. We agree with the initiation of ESA treatment when hemoglobin (Hb) level is 90-100 g/L; however, we specifically state that an acceptable range for Hb level is 95-115 g/L, with a target of 100-110 g/L, and add caution to individualization above this range due to concerns regarding the safety of ESAs. We agree that ESAs should be used with considerable caution in patients with active malignancy, history of stroke, or history of malignancy, and we suggest initiating ESA therapy at Hb level of 90 g/L and to aim for a Hb level in the range of 90-105 g/L. The reader is encouraged to note the level of evidence and review the entire KDIGO anemia guideline to interpret the guideline statements and commentary appropriately.

A Comparison of Quality of Life and Travel-Related Factors between In-center and Satellite-Based Hemodialysis Patients

BACKGROUND AND OBJECTIVES Shorter travel times and distance to dialysis clinics have been associated with improved patient outcomes and a higher health-related quality of life (HRQOL). The objective of this study was to compare HRQOL between prevalent in-center and satellite dialysis patients, as well as compare travel-related factors that contribute to HRQOL between in-center and satellite-based patients. DESIGN, SETTING, PARTICIPANTS, & MEASURES: The London Health Sciences Centre is a tertiary care center with in-center and regional satellite hemodialysis units. Patients who consented and completed a questionnaire (n = 202) were enrolled into a cross-sectional, cohort observational study. Patients were administered the Medical Outcomes Short-Form 36 (SF-36) and the Kidney Disease Health Related Quality of Life (KDHRQOL) tool and were asked questions relating to travel to dialysis clinics. RESULTS Patients who underwent dialysis in the satellites had similar demographics, comorbidities, and laboratory parameters. Patients who underwent dialysis in satellite units reported a significantly superior score on the dialysis stress domain of the KDHRQOL questionnaire. There was no significant difference between in-center and satellite patients on the basis of the SF-36. Satellite patients also reported a significantly decreased cost of transportation, a significantly increased proportion who drive themselves to clinics, and significantly decreased travel time. CONCLUSIONS Patients who underwent dialysis in satellite units demonstrated similar characteristics, comorbidities, surrogate outcomes, and most aspects of HRQOL. Travel time, cost, and receiving treatment in ones own community are important factors that may contribute to a trend toward higher reported HRQOL by patients in satellite dialysis units.

Understanding health decisions using critical realism: home-dialysis decision-making during chronic kidney disease.

Understanding health decisions using critical realism: home-dialysis decision-making during chronic kidney disease This paper examines home-dialysis decision making in people with Chronic Kidney Disease (CKD) from the perspective of critical realism. CKD programmes focus on patient education for self-management to delay the progression of kidney disease and the preparation and support for renal replacement therapy e.g.) dialysis and transplantation. Home-dialysis has clear health, societal and economic benefits yet service usage is low despite efforts to realign resources and educate individuals. Current research on the determinants of modality selection is superficial and insufficient to capture the complexities embedded in the process of dialysis modality selection. Predictors of home-dialysis selection and the effect of chronic kidney disease educational programmes provide a limited explanation of this experience. A re-conceptualization of the problem is required in order to fully understand this process. The epistemology and ontology of critical realism guides our knowledge and methodology particularly suited for examination of these complexities. This approach examines the deeper mechanisms and wider determinants associated with modality decision making, specifically who chooses home dialysis and under what circumstances. Until more is known regarding dialysis modality decision making service usage of home dialysis will remain low as interventions will be based on inadequate epistemology.

Sociodemographic differences in stressful experience and coping amongst adults with chronic kidney disease

AIM This secondary data analysis aims to determine whether stressful experiences and coping behaviours differ across age, gender and education level and if sociodemographic factors are independently associated with coping behaviour after controlling for stress. BACKGROUND Chronic kidney disease is stressful for individuals and their families; however, little research is available on this topic. METHODS In this cross-sectional quantitative study, information on stress and coping was obtained using the Chronic Kidney Disease Stress Inventory and the Jalowiec Coping Scale in 226 non-dialysis chronic kidney disease patients. The data were collected in Canada between 2005 and 2007. The independent effects of age, gender and education on coping behaviour were analysed in four multivariable regression models that adjusted for the three Chronic Kidney Disease Stress Inventory subscales separately, the total 34-item Chronic Kidney Disease Stress Inventory, and chronic kidney disease stage. RESULTS Stressful experience did not differ between the genders; however, women were more likely than men to report greater use of coping strategies. This relationship remained significant in each multivariable regression model. An inverse relationship between age and total coping use was significant in the multivariable model that adjusted for physiological stressors, but not in the models adjusting for psychosocial, logistic or total stressors. Significant relationships were observed between higher education and greater coping in bivariable analysis, but not multivariable analysis. CONCLUSION Knowledge of the relationships between sociodemographic factors, stressful experience and coping behaviour is necessary to develop and implement educative and supportive interventions further for chronic kidney disease patients and to provide the foundation for interventional and outcome investigations.

The advanced practice nurse–nephrologist care model: Effect on patient outcomes and hemodialysis unit team satisfaction

The tertiary care nurse practitioner/clinical nurse specialist (NP/CNS) is an advanced practice nurse with a relatively new role within the health‐care system. It is stated that care provided by the NP/CNS is cost‐effective and of high quality but little research exists to document these outcomes in an acute‐care setting. The clinical coverage pattern by nephrologists and NP/CNS of a hemodialysis unit in a large academic center allowed such a study. Two NP/CNS plus a nephrologist followed two of three hemodialysis treatment shifts per day; only a nephrologist followed the third shift. The influence of this care pattern of patients was examined using a cross‐sectional review of outcomes such as adequacy of delivered dialysis, anemia management, phosphate control, hospitalizations, etc. In addition, the level of satisfaction of the dialysis team and perceptions of care delivered with the care models was assessed. The care model staff‐to‐patient‐number ratio was similar in both groups (1:27 for NP/CNS plus nephrologist; 1:29 for nephrologist alone). Patient demographics were similar in both groups but the NP/CNS–nephrologist group had patients with more comorbidities. No statistically significant (p < 0.05) differences existed between the groups in patient laboratory data, adherence to standards, medications, inter‐ and intradialytic blood pressure, achievement of target postdialysis weights, and hospitalizations or emergency room visits. Significantly more adjustments were made to target weights and medications and more investigations were ordered by the NP/CNS–nephrologist team. Team satisfaction and perceptions of care delivery were higher with the NP/CNS–nephrologist model. It is concluded that the NP/CNS–nephrologist care model may increase the efficiency of the care provided by nephrologists to chronic hemodialysis patients. The model may also be a solution to the problem of providing nephrologic care to an ever‐growing hemodialysis population.

A new measure of ‘lay’ care-giver activities

The Lay Care-Giving for Adults Receiving Dialysis (LC-GAD) was developed using qualitative and quantitative approaches to systematically measure the breadth and quantity of caregiver activities. The reliability and validity of these evaluations was tested on a sample of 447 Canadian family members and friends who cared for adults on dialysis. Factor analysis was performed independently assessing two components. The first measured the abstract, cognitive work of care-giving (Think-LC-GAD) which included the subscales of appraisal, advocating, coaching, juggling and routinizing. These five factors explained two-thirds of the total variance of the Think-LC-GAD. The second component measured the concrete tasks of care-giving (Task-LC-GAD) which included providing transportation, performing dialysis, personal hygiene, diet, symptom relief, comfort measures and teaching self-care. These seven factors explained seven-eights of the total variance in the Task-LCGAD. Test-retest reliability of these two components had significant correlation coefficients. The validity of the Think- and Task-LC-GADs showed positive correlations between themselves and the perceived burden of care-giving, the trait of conscientiousness and self-reported self-care abilities.

Chronic kidney disease stressors influence choice of dialysis modality

AIM   This article is a report of a study examining the relationships between chronic kidney disease stressors and coping strategies with dialysis modality. BACKGROUND   People with chronic kidney disease are given information to enable dialysis modality choice. This education increases awareness and may alleviate concerns and stress. Disease-related stressors and coping may affect dialysis selection. Understanding the influence of stress and coping on dialysis choices will assist in providing responsive programmes. Reducing stress and encouraging coping may increase home dialysis which, despite economic and patient benefits, remains underused. DESIGN   A prospective correlational design was used. METHODS   Information was obtained from the Chronic Kidney Disease Stress Inventory and the Jalowiec Coping Scale in 223 individuals not on dialysis between the years 2005-2007. Data were recorded with respect to modality at dialysis initiation (n = 76) from 2005-2010. The effects of stress, coping and patient parameters on modality selection were compared using bivariate and multivariate analyses. RESULTS   Individuals on home dialysis vs. in-centre haemodialysis reported significantly fewer pre-dialysis stressors. Coping was not associated with dialysis modality. Individuals on in-centre haemodialysis had a lower serum creatinine, less advanced kidney disease and weighed more than those who started on a home therapy. Physiological stressors were most common and are amenable to interventions. CONCLUSION   Pre-dialysis stress levels predicted dialysis modality. Interventional studies are recommended to address chronic kidney disease stressors with the outcome of improving home-dialysis usage.

Educational Support Around Dialysis Modality Decision Making in Patients With Chronic Kidney Disease: Qualitative Study

Background: Patients with chronic kidney disease (CKD) are asked to choose a renal replacement therapy or conservative management. Education and knowledge transfer play key roles in this decision-making process, yet they remain a partially met need. Objective: We sought to understand the dialysis modality decision-making process through exploration of the predialysis patient experience to better inform the educational process. Design: Qualitative descriptive study. Setting: Kidney Care Centre of London Health Sciences Centre in London, Ontario, Canada. Patients: Twelve patients with CKD, with 4 patients on in-center hemodialysis, home hemodialysis, and peritoneal dialysis, respectively. Measurements: Not applicable. Methods: We conducted semistructured interviews with each participant, along with any family members who were present. Interviews were transcribed verbatim. Conventional content analysis was used to analyze the transcripts for common themes. Representative quotes were decided via team consensus. A patient collaborator was part of the research team. Results: Three themes influenced dialysis modality decision making: (i) Patient Factors: individualization, autonomy, and emotions; (ii) Educational Factors: tailored education, time and preparation, and available resources; and (iii) Support Systems: partnership with health care team, and family and friends. Limitations: Sample not representative of wider CKD population. Limited number of eligible patients. Poor recall may affect findings. Conclusions: Modality decision making is a complex process, influenced by the patient’s health literacy, willingness to accept information, predialysis lifestyle, support systems, and values. Patient education requires the flexibility to individualize the delivery of a standardized CKD curriculum in partnership with a patient-health care team, to fulfill the goal of informed, shared decision making.

Understanding skill acquisition among registered nurses: the ‘perpetual novice’ phenomenon

AIMS AND OBJECTIVES To determine whether the perpetual novice phenomenon exists beyond nephrology nursing where it was first described. BACKGROUND The perpetual novice is a state in which nurses are unable to progress from a novice to an expert in one or more essential clinical skills which are used in their practice area. Maintaining clinical competence is essential to quality patient care outcomes. DESIGN An exploratory, sequential, mixed methods design was used, comprised of a quantitative component followed by in-depth interviews. METHODS Registered nurses employed in one of four roles were recruited from two university-affiliated hospitals in London, Ontario, Canada: Clinical Educator, Clinical Nurse Specialist, Advanced Practice Nurse and Nurse Practitioner. Participants were first asked to complete and return a survey and demographic questionnaire. Following the return of the completed surveys, ten participants were interviewed to enhance the results of the surveys. RESULTS The results of the surveys confirmed that the perpetual novice phenomenon exists across multiple nursing care areas. Four contributing factors, both personal and structural in nature, emerged from the interviews: (1) opportunities for education, (2) the context of learning, (3) personal motivation and initiative to learn and (4) the culture of the units where nurses worked. CONCLUSION The perpetual novice phenomenon exists due to a combination of both personal factors as well as contextual factors in the work environment. RELEVANCE TO CLINICAL PRACTICE The results assist in directing future educational interventions and provide nursing leaders with the information necessary to create work environments that best enable practicing nurses to acquire and maintain clinical competence.