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A correction to the article "Left Ventricular Twist Mechanics and its Relation With Aortic Stiffness in Chronic Kidney Disease Patients Without Overt Cardiovascular Disease," published in "Cardiovascular Ultrasound," is presented.

Health inequity refers to the existence of unnecessary and unfair differences in the ability of an individual or community to achieve optimal health and access appropriate care. Kidney diseases, including acute kidney injury and chronic kidney disease, are the epitome of health inequity. Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of disease. Insufficient investment across the spectrum of kidney health and kidney care is a fundamental source of inequity. In addition, social and structural inequities, including inequities in access to primary health care, education and preventative strategies, are major risk factors for, and contribute to, poorer outcomes for individuals living with kidney diseases. Access to affordable kidney care is also highly inequitable, resulting in financial hardship and catastrophic health expenditure for the most vulnerable. Solutions to these injustices require leadership and political will. The nephrology community has an important role in advocacy and in identifying and implementing solutions to dismantle inequities that affect kidney health. Kidney disease risk and outcomes are strongly associated with inequities that occur across the entire clinical course of the disease. The authors of this Review describe the different inequities that affect kidney health and care worldwide, and consider potential solutions to help to mitigate these. Key points: Insufficient investment across the spectrum of kidney health and kidney care (from raising awareness of kidney disease, to its prevention, diagnosis and treatment) is a fundamental source of inequity, and affects all people at risk of, or living with, kidney diseases. Social and structural inequities are major risk factors for, and contribute to, poor outcomes for individuals living with kidney diseases. Access to essential diagnostics and medications for kidney disease is inequitable and insufficient, as are programmes to track their burden; these insufficiencies disadvantage patients in low- and middle-income countries from early in their disease course. The ability to access kidney care across the spectrum of disease without exposure to financial hardship is very inequitable; this inequity results in vastly different outcomes and life courses for patients who have the same diseases but live under different circumstances. Novel therapies for rare (orphan) diseases are often only available at extremely high prices; their use in children is often not adequately documented and the cost of these medications exacerbates inequities. All nephrology professionals should become skilled at advocating on behalf of their patients to communities, policy makers, administrators and insurers to develop constructive strategies and collectively reach optimal solutions to improve equity in the accessibility of quality kidney care locally and across the globe. [ABSTRACT FROM AUTHOR]

The article presents a comment on the study "Age is not a contraindication to home-based dialysis - Quality of Life outcomes favour older patients on peritoneal dialysis regimes relative to younger patients," by K. Griva and colleagues, which concluded that more older patients are dependent on carers compared to younger ones. Topics discussed include the benefits of peritoneal dialysis on older patients' quality of life (QOL) and the need to understand how medical costs affects patients' QOL.

Supportive care (SC) is a multidimensional and person-centred approach to managing advanced CKD that engages the person and their caregivers in shared decision making from the outset. Rather than focusing on disease-specific therapies, SC is a collection of adjuvant interventions and adaptations to conventional treatments that can be used to improve the individual's quality of life. Recognizing that frailty, multi-morbidity and polypharmacy are more common among older people with advanced chronic kidney disease (CKD) and that people in this group tend to prioritize quality of life over survival as a goal of care, SC represents an important adjunct to disease-specific therapies in CKD management. This review provides an overview of SC in the older person with advanced CKD. [ABSTRACT FROM AUTHOR]

The author discusses various issues related to the appropriateness and selection of therapies including hospital haemodialysis (HD) and peritoneal dialysis (PD) for patients requiring dialysis. He mentions the benefits of PD in providing home therapy for older patients. He further highlights the disadvantage associated with haemodynamic instability of hospital haemodialysis (HD) including the cost of treatment, transport and time to recover from dialysis session.

Barriers to accessing home dialysis became a matter of life and death for many patients with kidney failure during the coronavirus disease 2019 (COVID-19) pandemic. Peritoneal dialysis (PD) is the more commonly used home therapy option. This article provides a comprehensive analysis of PD catheter insertion procedures as performed around the world today, barriers impacting timely access to the procedure, the impact of COVID-19 and a roadmap of potential policy solutions. To substantiate the analysis, the article includes a survey of institutions across the world, with questions designed to get a sense of the regulatory frameworks, barriers to conducting the procedure and impacts of the pandemic on capability and outcomes. Based on our research, we found that improving patient selection processes, determining and implementing correct insertion techniques, creating multidisciplinary teams, providing appropriate training and sharing decision making among stakeholders will improve access to PD catheter insertion and facilitate greater uptake of home dialysis. Additionally, on a policy level, we recommend efforts to improve the awareness and feasibility of PD among patients and the healthcare workforce, enhance and promulgate training for clinicians—both surgical and medical—to insert PD catheters and fund personnel, pathways and physical facilities for PD catheter insertion. [ABSTRACT FROM AUTHOR]

Background Randomized trials can provide evidence to inform decision-making but this may be limited if the outcomes of importance to patients and clinicians are omitted or reported inconsistently. We aimed to assess the scope and heterogeneity of outcomes reported in trials in peritoneal dialysis (PD). Methods We searched the Cochrane Kidney and Transplant Specialized Register for randomized trials in PD. We extracted all reported outcome domains and measurements and analyzed their frequency and characteristics. Results From 128 reports of 120 included trials, 80 different outcome domains were reported. Overall, 39 (49%) domains were surrogate, 23 (29%) patient-reported and 18 (22%) clinical. The five most commonly reported domains were PD-related infection [59 (49%) trials], dialysis solute clearance [51 (42%)], kidney function [45 (38%)], protein metabolism [44 (37%)] and inflammatory markers/oxidative stress [42 (35%)]. Quality of life was reported infrequently (4% of trials). Only 14 (12%) trials included a patient-reported outcome as a primary outcome. The median number of outcome measures (defined as a different measurement, aggregation and metric) was 22 (interquartile range 13–37) per trial. PD-related infection was the most frequently reported clinical outcome as well as the most frequently stated primary outcome. A total of 383 different measures for infection were used, with 66 used more than once. Conclusions Trials in PD include important clinical outcomes such as infection, but these are measured and reported inconsistently. Patient-reported outcomes are infrequently reported and nearly half of the domains were surrogate. Standardized outcomes for PD trials are required to improve efficiency and relevance. [ABSTRACT FROM AUTHOR]

Background While peritoneal dialysis (PD) can offer patients more independence and flexibility compared with in-center hemodialysis, managing the ongoing and technically demanding regimen can impose a burden on patients and caregivers. Patient empowerment can strengthen capacity for self-management and improve treatment outcomes. We aimed to describe patients' and caregivers' perspectives on the meaning and role of patient empowerment in PD. Methods Adult patients receiving PD (n  = 81) and their caregivers (n  = 45), purposively sampled from nine dialysis units in Australia, Hong Kong and the USA, participated in 14 focus groups. Transcripts were thematically analyzed. Results We identified six themes: lacking clarity for self-management (limited understanding of rationale behind necessary restrictions, muddled by conflicting information); PD regimen restricting flexibility and freedom (burden in budgeting time, confined to be close to home); strength with supportive relationships (gaining reassurance with practical assistance, comforted by considerate health professionals, supported by family and friends); defying constraints (reclaiming the day, undeterred by treatment, refusing to be defined by illness); regaining lost vitality (enabling physical functioning, restoring energy for life participation); and personal growth through adjustment (building resilience and enabling positive outlook, accepting the dialysis regimen). Conclusions Understanding the rationale behind lifestyle restrictions, practical assistance and family support in managing PD promoted patient empowerment, whereas being constrained in time and capacity for life participation outside the home undermined it. Education, counseling and strategies to minimize the disruption and burden of PD may enhance satisfaction and outcomes in patients requiring PD. [ABSTRACT FROM AUTHOR]

• In the frail elderly dialysis population falls are frequently encountered. • Fall incidence is comparable between elderly hemodialysis and assisted peritoneal dialysis patients. • Diabetes and previous falls are associated with new falls in frail elderly patients. • Literature shows frailty is related to falling and falling increases the risk of mortality and hospitalization. • Falls negatively impact QoL, as fallers have a higher prevalence of fear of falling and perform limited activities. As the numbers of older patients on dialysis rise, geriatric problems such as falling become more prevalent. We aimed to assess the prevalence of falls and the impact on mortality and quality of life in frail elderly patients on assisted PD (aPD) and hemodialysis (HD) from the FEPOD Study. Data on falls and quality of life were collected with questionnaires at baseline and every six months during 2-year follow-up. Multiple regression analysis was used to evaluate factors associated with falls. Additionally, we performed a review of literature concerning the relation between falls and poor outcome. Baseline fall data were available for 203 patients and follow-up data for 114 patients. Dialysis modality was equally distributed (49% HD and 51% aPD). Mean (SD) age was 75 ± 7 years. Fall rate was 1.00 falls/patient year, comparable in HD and aPD. Falls led to fear of falling, resulting in less activities in 68% vs 42% (p < 0.01) and leaving the house less in 59% vs 31% (p < 0.01) of patients. Patients with diabetes mellitus were twice as likely to report falls at baseline (OR 1.91 [95%CI 1.00–3.63], p = 0.05) and falls at baseline were associated with falls during follow-up (OR 2.53 [95%CI 1.06–6.04] p = 0.03). Literature revealed frailty was a strong risk factor for falling and falling results in a higher mortality and hospitalization rate. Falls were frequent in older dialysis patients and have a negative impact on quality of life. Fall incidence is comparable between aPD and HD. [ABSTRACT FROM AUTHOR]

The number of elderly patients on maintenance dialysis has rapidly increased in the past few decades, particularly in developed countries, imposing a growing burden on dialysis centres. Hence, many nephrologists and healthcare authorities feel that greater emphasis should be placed on the promotion of home dialysis therapies such as peritoneal dialysis (PD) and home haemodialysis (HD). There is currently no general consensus as to the best dialysis modality for elderly patients with end-stage renal disease. In-centre HD is predominant in most countries, although it is widely recognized that PD has several advantages over HD, including the lack of need for vascular access, continuous slow ultrafiltration, less interference with patients' lifestyle and lower costs. Comparisons of outcomes between elderly patients on PD and HD rely on observational studies, as randomized controlled trials are lacking. The results of these studies are variable. However, most of them suggest that survival rates are largely similar between the two modalities, except for elderly patients with diabetes and/or beyond 1-3 years from dialysis initiation, in which cases HD appears to be superior. An equally important aspect to consider when choosing dialysis modality, particularly in this age group, is the quality of life, and in this regard most studies found no significant differences between PD and HD. In these circumstances, we believe that dialysis modality selection should be guided by patient's preference, based on comprehensive and unbiased information. A multidisciplinary team should review elderly patients starting on dialysis, aiming to identify possible barriers to PD and home HD, including physical, visual, cognitive, psychological and social problems, and to overcome such barriers by adequate care, education, psychological counselling and dialysis assistance. [ABSTRACT FROM AUTHOR]

Patients with advanced chronic kidney disease (CKD) have a high burden of physical and psychosocial symptoms, poor outcomes, and high costs of care. Current paradigms of care for this highly vulnerable population are variable, prognostic and assessment tools are limited, and quality of care, particularly regarding conservative and palliative care, is suboptimal. The KDIGO Controversies Conference on Supportive Care in CKD reviewed the current state of knowledge in order to define a roadmap to guide clinical and research activities focused on improving the outcomes of people living with advanced CKD, including those on dialysis. An international group of multidisciplinary experts in CKD, palliative care, methodology, economics, and education identified the key issues related to palliative care in this population. The conference led to a working plan to address outstanding issues in this arena, and this executive summary serves as an output to guide future work, including the development of globally applicable guidelines. [ABSTRACT FROM AUTHOR]

Background. We previously validated a scoring system for abdominal/pelvic CT scans in patients with symptomatic encapsulating peritoneal sclerosis (EPS). CT scans of patients with symptomatic EPS were significantly different from control peritoneal dialysis (PD) or haemodialysis patient scans; scans performed before EPS was clinically evident were near normal in 9 of 13 patients. We have now investigated CT scanning as a screening modality in a larger group of patients on long-term PD.Methods. Pre-diagnostic CT scans performed in 20 patients for routine screening or other indications at least 3 months before EPS developed, and later diagnostic scans when EPS was clinically evident, were scored by three radiologists. The control group included CT scans of 20 PD patients who had not developed EPS (median follow-up 2.25 years). Analysis was by non-parametric tests. CT scores ranged from 0 to 22; > 2.5 was considered abnormal.Results. Clinical EPS only developed after transplantation or transfer to HD. Diagnostic scans scored significantly higher than pre-diagnostic or control scans (median scores 9, 2 and 1; P < 0.001), confirming previous work. The pre-EPS diagnosis of 12 asymptomatic patients had a median CT score = 1.75, similar to the control group. Eight patients had had a limited episode of abdominal symptoms (seven required hospitalization), but did not have the clinical picture of EPS; their median CT score was 4.5 (P = 0.0016 cf control group). The time from pre-diagnostic scan to clinical EPS (median 0.82 years) and duration of PD at time of pre-diagnostic scan (median 7.1 years) did not differ significantly between the symptomatic and asymptomatic groups.Conclusions. CT screening of asymptomatic PD patients is not indicated; EPS may occur within a year or less of a normal CT scan. Abdominal symptoms in long-term PD patients can be associated with CT scan abnormalities; these patients are at increased risk of EPS after stopping PD. [ABSTRACT FROM AUTHOR]

Background Peritoneal fibrosis manifests clinically as membrane failure or encapsulating peritoneal sclerosis (EPS). There are no clinical or biochemical tests to determine the rate of progression of peritoneal fibrosis. CCL18 ⁄ pulmonary and activation-regulated chemokine (PARC) is profibrotic and stimulates collagen production independent of the effect of transforming growth factor beta. This has not been studied in peritoneal dialysis (PD) patients. Materials and methods We have prospectively studied 106 patients, free from infection ⁄ recent peritonitis. A high concentration of CCL18 was discovered by multiplex antibody arrays and quantified by ELISA. Serum and dialysate levels were examined for their prognostic values. Results By multiple regression analysis, dialysate CCL18 (6Æ76 ± 0Æ66 lg 4 h)1) correlated with increasing membrane transport status (TS) (P < 0Æ0001) and total glucose exposure ⁄ 24 h (P = 0Æ033). Serum CCL18 correlated with high TS (P = 0Æ0001) and duration of PD (P = 0Æ001). After 12 months of follow-up, 57 patients remained on PD while 12 patients were transferred to haemodialysis (HD) and seven developed EPS. Patients who subsequently developed EPS had higher baseline dialysate CCL18 (11Æ5 ± 3Æ6 lg 4 h)1 vs. 5Æ6 ± 0Æ82 lg 4 h)1, P = 0Æ03) and serum CCL18 (156 Æ9 ± 12Æ8 ng mL)1 vs. 124Æ8 ± 12Æ2 ng mL)1, P = 0Æ02) compared with the stable PD group. Conclusion This is the first report of high levels of CCL18 in the spent dialysate and serum from long-term PD patients. These levels correlated with dysfunction of peritoneal membrane transport status, therefore following CCL18 in a longitudinal study may be of interest. [ABSTRACT FROM AUTHOR]

SummaryBackground: Evidence-based health policy is urgently needed to meet the increasing demand for health services among elderly people, particularly for expensive technologies such as renal-replacement therapy. Age has been used to ration dialysis, although not always explicitly, despite the lack of rigorous empirical evidence about how elderly people fare on dialysis. We undertook a comprehensive assessment of outcomes in patients 70 years or over.Methods: We did a 12-month prospective cohort study of outcomes in 221 patients with end-stage renal failure aged 70 years or over recruited from four hospital-based renal units. We assessed 1-year survival in 125 incident patients (70-86 years) and disease burden (hospital admissions, quality of life, costs) in 174 prevalent patients (70-93 years).Findings: 1-year survival rates were: 71% overall; 80%, 69%, and 54% in patients 70-74 years, 75-79 years, and 80 years and older, respectively (p=0.008); and 88%, 71%, and 64% in patients with no, one, or two or more comorbid conditions, respectively (p=0.056). Cox regression analyses showed that mortality was significantly associated with age 80 years and older (relative risk 2.79 [95% CI 1.28-6.93]) and peripheral vascular disease (2.83 [1.29-6.17]), but not with diabetes, ischaemic heart disease, cerebrovascular disease, chronic obstructive airways disease, sex, or treatment method. In terms of disease burden, hospital admissions represent a low proportion of costs and was not required by a third of patients, mental quality of life in elderly dialysis patients was similar to that of elderly people in the general population, and the average annual cost per patient of _GCP_20 802 (US$31 200) (68% dialysis treatment, 1% transport, 19% inpatient hospital admissions, 12% medications) was within the range of other life-extending interventions.Interpretation: Our results suggest that age alone should not be used as a barrier to referral and treatment and emphasise the... [ABSTRACT FROM AUTHOR]

Background: Intraperitoneal pressure measurement offers therapeutic and prognostic benefits in predicting leak risks and gastrointestinal symptoms in Peritoneal Dialysis (PD) patients. This systematic review aims to evaluate the prognostic utility of intraperitoneal pressure measurements and different estimated intraperitoneal pressure equations in predicting the risk of non-infectious complications in PD patients., Methods: Databases including MEDLINE, EMBASE and Cochrane were searched up to July 2023. Randomised and non-randomised trials were included, focusing on End-Stage Kidney Disease (ESKD) patients undergoing PD. Primary outcomes were variables associated with intraperitoneal pressure, while secondary outcomes included PD-related non-infectious complications and gastrointestinal symptoms. Data synthesis combined meta-analysis with narrative synthesis. This review has been registered on PROSPERO (CRD42023475138)., Results: Out of 1828 identified studies, 12 were included for systematic review and 10 for meta-analysis. Body Mass Index (BMI) and Body Surface Area (BSA) showed a consistent positive correlation with intraperitoneal pressure (BMI: r = 0.49, 95% CI 0.35-0.61, I 2  = 67.39%, p = 0.003; BSA: r = 0.2, 95% CI 0.08-0.31, I 2  = 14.10%, p = 0.324). Conversely, the association between intraperitoneal pressure and age, intraperitoneal volume, and Charlson Comorbidity Index were less consistent. Subgroup analysis demonstrated an association between higher intraperitoneal pressure in patients with increased BMI and BSA. However, the relationship between intraperitoneal pressure and non-infectious mechanical complications remained inconclusive., Discussion: This review underscores a significant association between intraperitoneal pressure and anthropometric measures (BMI and BSA). The majority of the studies identified included a small sample and considerable bias. However, the association between intraperitoneal pressure and clinically relevant outcomes was not clear., Conclusions: While increasing body mass index and body surface areas are associated with increasing intraperitoneal pressure, the clinical relevance of measuring intraperitoneal pressure in an adult population remains unclear, particularly given the absence of an association with clinically relevant non-infectious outcomes., (© 2024. The Author(s) under exclusive licence to Italian Society of Nephrology.)

Use of peritoneal dialysis and home haemodialysis remains low in Europe, with the highest use in Scandinavian countries and the lowest in Eastern and Central Europe despite the advantages for people on dialysis and economic advantages for healthcare systems. This is partly due to the impact of the haemodialysis industry resulting in proliferation of haemodialysis units and nephrologist reimbursement related to use of haemodialysis. Equally important is the bias against home dialysis at both clinician and healthcare system levels. The underlying causes of this bias are discussed in relation to a mechanistic view of the human body, lack of compassion, failure to adjust dialysis provision for older age and frailty, proliferation of small dialysis centres, and complexity of decision-making and clinical care. For home dialysis to flourish, we need to foster a change in attitude to and vision of the aims of healthcare so that enabling meaningful activities of people requiring dialysis, as explored in the Standardized Outcomes in Nephrology initiative, rather than achieving biological numbers become the focus of care delivery., Competing Interests: Edwina Brown: speaker fees from Baxter Healthcare and Fresenius Medical Care., (© The Author(s) 2024. Published by Oxford University Press on behalf of the ERA.)

Competing Interests: Declaration of conflicting interestsMJO is an owner of DMAR systems; Honoraria: Baxter Healthcare; Contracted Medical; employed as a Medical Lead at Ontario Renal Network, Ontario Health. GA has received consulting fees from Baxter Healthcare. EAB had received speaker and consulting fees from Baxter Healthcare, Fresenius Medical Care, Vifor, AWAK and liberDi; DWJ has received consultancy fees, research grants, speaker’s honoraria and travel sponsorships from Baxter Healthcare and Fresenius Medical Care, consultancy fees from Astra Zeneca, Bayer and AWAK, speaker’s honoraria from ONO and Boehringer Ingelheim & Lilly and travel sponsorships from Ono and Amgen. He is a current recipient of an Australian National Health and Medical Research Council Leadership Investigator Grant. AMG has received speaker and consulting fees from Baxter Healthcare. VJ has received grant funding consultancy Fees and honoraria from Bayer, AstraZeneca, Boehringer Ingelheim, NephroPlus, Biocryst, Vera, Visterra, Otsuka, Chinook and Zydus Cadilla; TK has received consultancy fees from VISTERRA, ELEDON, Otsuka OLE and Otsuka VISIONARY as country investigators and is current recipients of the National Research Council of Thailand and the Royal College of Thailand Physician and received speaking honoraria from Astra Zeneca and Baxter Healthcare. PL received speaker Honoraria from AstraZeneca, Baxter Healthcare and Fibrogen; UHL has received speaker and consultancy engagements for Baxter Healthcare and Fresnenius Medical Care. TL received speaker Honoraria from Astellas, Baxter.

Peritoneal dialysis (PD) enables people to have a home-based therapy, permitting greater autonomy for individuals along with enhanced treatment satisfaction compared with in-center dialysis care. The burden of treatment on PD, however, remains considerable and underpins the need for person-centered care. This reflects the need to address the patient as a person with needs and preferences beyond just the medical perspective. Shared decision making is central to the recent International Society for Peritoneal Dialysis recommendations for prescribing PD, balancing the potential benefits of PD on patient well-being with the burden associated with treatment. This review considers the role of high-quality goal-directed prescribing, incremental dialysis, and remote patient monitoring in reducing the burden of dialysis, including an approach to implementing incremental PD. Although patient-related outcomes are important in assessing the response to treatment and, particularly life participation, the corollary of dialysis burden, there are no clear routes to the clinical implementation of patient-related outcome measures. Delivering person-centered care is dependent on treating people both as individuals and as equal partners in their care., (Copyright © 2023 by the American Society of Nephrology.)

Background: Peritoneal dialysis provides several benefits for patients and should be offered as first line kidney replacement therapy, particularly for fragile patients. Limitation to self-care drove assisted peritoneal dialysis to evolve from family-based care to institutional programs, with specialized care givers. Some European countries have mastered this, while others are still bound by the availability of a volunteer to become responsible for treatment., Methods: A group of leading nephrologists from 13 European countries integrated real-life application of such therapy, highlighting barriers, lessons learned and practical solutions. The objective of this work is to share and summarize several different approaches, with their intrinsic difficulties and solutions, which might helpperitoneal dialysis units to develop and offer assisted peritoneal dialysis., Results: Assisted peritoneal dialysis does not mean 4 continuous ambulatory peritoneal dialysis exchanges, 7 days/week, nor does it exclude cycler. Many different prescriptions might work for our patients. Tailoring PD prescription to residual kidney function, thereby maintaining small solute clearance, reduces dialysis burden and is associated with higher technique survival. Assisted peritoneal dialysis does not mean assistance will be needed permanently, it can be a transitional stage towards individual or caregiver autonomy. Private care agencies can be used to provide assistance; other options may involve implementing PD training programs for the staff of nursing homes or convalescence units. Social partners may be interested in participating in smaller initiatives or for limited time periods., Conclusion: Assisted peritoneal dialysis is a valid technique, which should be expanded. In countries without structural models of assisted peritoneal dialysis, active involvement by the nephrologist is needed in order for it to become a reality., (© 2023. The Author(s).)

Rationale & Objective: Greater prognostic understanding is associated with higher quality care at the end of life. We undertook a scoping review to explore how long dialysis recipients expect to live., Study Design: Scoping Review., Setting & Study Populations: People with kidney failure over 18 years old., Search Strategy & Sources: Studies were identified by searching Medline, Embase, APA PsycINFO, HMIC, and ProQuest database for terms related to "life expectancy", "self-estimated", and "end stage kidney disease"., Data Extraction: Search strategies reported 349 unique, potentially eligible studies, with 8 studies meeting the inclusion criteria after screening., Results: Significant mismatches between dialysis recipients and their health care provider's estimations of prognosis were reported, with patients predicting significantly higher life expectancies than health care professionals and almost no agreement between patient and nephrologist's estimates of 1-year survival. Documented cognitive impairment did not affect 1-year or 5-year prognosis estimates, nor did gender, age, time on dialysis, or discussing perceived life expectancy. Dialysis recipients who thought they were on the transplant list or who self-identified as African American reported higher perceived life expectancy, whereas people who were 75 years or older, or with fair or poor self-reported health status reported a lower perceived life expectancy. Those with a lower perceived life expectancy preferred care focusing on relieving pain and discomfort, whereas people who thought they had a higher chance of survival were significantly more likely to prefer life-extending care., Limitations: There is a marked paucity of research in this area, with most studies conducted in North American cohorts., Conclusions: Optimistic patient prognostic expectations persist in dialysis recipients. Given the effects of perceived life expectancy on treatment choices and subsequent quality of life, it is important that transparent discussions regarding prognosis are conducted with people receiving dialysis and their families., Plain-Language Summary: Understanding illness severity and prognosis allows people to make decisions and prioritize areas of their lives that are important to them. We undertook a scoping review to explore how long dialysis recipients expect to live. We found significant mismatches between the perceived life expectancy of people treated with dialysis and their health care providers. Perceived life expectancy influenced treatment choices; thus, those who thought they would die sooner prioritized care focusing on relieving pain and discomfort. Those who thought they had a higher chance of survival were more likely to prefer life-extending care (with potential effects on quality of life). It is important to have frank discussions about prognosis with people receiving dialysis, to empower individuals and help them make informed decisions about their care., (© 2023 The Authors.)

Peritoneal dialysis (PD) catheter-related infections are important risk factors for catheter loss and peritonitis. The 2023 updated recommendations have revised and clarified definitions and classifications of exit site infection and tunnel infection. A new target for the overall exit site infection rate should be no more than 0.40 episodes per year at risk. The recommendation about topical antibiotic cream or ointment to catheter exit site has been downgraded. New recommendations include clarified suggestion of exit site dressing cover and updated antibiotic treatment duration with emphasis on early clinical monitoring to ascertain duration of therapy. In addition to catheter removal and reinsertion, other catheter interventions including external cuff removal or shaving, and exit site relocation are suggested.

Encapsulating peritoneal sclerosis (EPS) is a clinical syndrome hallmarked by the formation of a fibrous cocoon encapsulating the bowel resulting in morbidity and mortality. EPS is most frequently associated with peritoneal dialysis (PD), particularly with its discontinuation. While EPS is one of the most feared complications of PD, the majority of patients receiving PD will not go on to develop EPS. Risk factors for development include time on PD, some types of peritonitis and discontinuation of PD. Owing to its rarity, much of the knowledge of EPS comes from case series and registries and treatments are extrapolated from low-quality evidence. Malnutrition is a significant driver of mortality, and nutritional support is critical in management. We present a case of EPS and frequently asked questions including the definition, diagnosis, epidemiology, pathophysiology, risk factors, role of infection, management and roles of nutrition and surgery.

Background: Older people with end-stage kidney disease (ESKD) are vulnerable to frailty, which impacts on clinical and experiential outcomes. With kidney transplantation in older people increasing, a better understanding of patient experiences is necessary for guiding decision making. The Kidney Transplantation in Older People (KTOP):impact of frailty on outcomes study aims to explore this. We present a secondary analysis of the Edmonton Frail Scale (EFS) and its relationship with patient experience scores., Methods: The KTOP study is a single centre, prospective study, which began in October 2019. All ESKD patients aged ≥60 considered for transplantation at Imperial College Renal and Transplant Centre were eligible. Frailty was assessed using the EFS and 5 questionnaires assessed patient experience and quality of life (QoL) (Short Form-12(v2), Palliative Care Outcome Scale-Symptoms Renal, Depression Patient Health Questionnaire-9, Illness Intrusiveness Ratings Scale, Renal Treatment Satisfaction Questionnaire). The EFS was divided into 4 subdomains (psychosocial, physical function, medical status, and general health) and then compared with the questionnaire scores., Results: 210 patients have been recruited (aged 60-78), 186 of whom completed EFS assessments. 118 (63.4%) participants were not frail, 36 (19.4%) vulnerable, and 32 (17.2%) were frail. Worse frailty scores were associated with poorer patient experience and QoL scores across all questionnaires. Severe deficits in the EFS psychosocial subdomain showed a statistically significant association with higher depression screen scores (coefficient 4.9, 95% CI 3.22 to 6.59), lower physical (coefficient -4.35, 95% CI -7.59 to -1.12) and mental function scores (coefficient -8.33, 95% CI -11.77 to -4.88) from the Short Form-12(v2), and lower renal treatment satisfaction scores (coefficient -5.54, 95% CI -10.70 to -0.37). Deficits in the physical function and medical status EFS subdomians showed some association with patient experience scores., Conclusion: In the KTOP study cohort at recruitment vulnerable and frail candidates reported worse QoL and patient experiences. Severe deficits in the psychosocial subdomains of the EFS showed a strong association with patient experience and QoL, whilst physical function and medical status deficits showed a lesser association. This has highlighted specific EFS domains that may be suitable for targeted interventions to improve experiences and optimise outcomes., Competing Interests: EB – Baxter Healthcare: speaker fees and advisory board; AWAK – advisory board; liberDi – advisory board. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be constructed as a potential conflict of interest., (Copyright © 2023 Thind, Levy, Wellsted, Willicombe and Brown.)

We have developed a supportive two-exchange assisted continuous ambulatory peritoneal dialysis (asCAPD) programme for the older frail person who cannot do autonomous PD and do not want or are considered to be too high risk for haemodialysis (HD). Evaluation of the programme was determined by data collected retrospectively from patient records. Primary outcome was comparison of symptoms at start of dialysis and 3 months following dialysis start. Secondary outcomes were survival and peritonitis rate. Over a 4-year period (2016-2020), 49 patients with mean age 79.6 years (range 47-90) enrolled in the programme with eGFR 7.7 ± 2.6 ml/min (mean ± SD) at dialysis start. Forty-one patients had been on asCAPD for > 3 months. There was an improvement in all symptoms at 3 months compared to baseline: anorexia (46% to 15%), fatigue (46% to 15%), shortness of breath (27% to 2%) and oedema (51% to 32%). One-year survival was 55%. Peritonitis rate was 0.52 episodes per patient year. The novel supportive two-exchange asCAPD programme shows potential improvement of symptoms after 3 months and may provide an acceptable dialysis modality for the frail co-morbid person with established kidney failure. More detailed study and evaluation are needed.

Supportive care (SC) is a multidimensional and person-centred approach to managing advanced CKD that engages the person and their caregivers in shared decision making from the outset. Rather than focusing on disease-specific therapies, SC is a collection of adjuvant interventions and adaptations to conventional treatments that can be used to improve the individual's quality of life. Recognizing that frailty, multi-morbidity and polypharmacy are more common among older people with advanced chronic kidney disease (CKD) and that people in this group tend to prioritize quality of life over survival as a goal of care, SC represents an important adjunct to disease-specific therapies in CKD management. This review provides an overview of SC in the older person with advanced CKD., Competing Interests: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Background: Availability of assisted PD (asPD) increases access to dialysis at home, particularly for the increasing numbers of older and frail people with advanced kidney disease. Although asPD has been widely used in some European countries for many years, it remains unavailable or poorly utilized in others. A group of leading European nephrologists have therefore formed a group to drive increased availability of asPD in Europe and in their own countries., Methods: Members of the group filled in a proforma with the following headings: personal experience, country experience, who are the assistants, funding of asPD, barriers to growth, what is needed to grow and their top three priorities., Results: Only 5 of the 13 countries surveyed provided publicly funded reimbursement for asPD. The use of asPD depends on overall attitudes to PD, with all respondents mentioning the need for nephrology team education and/or patient education and involvement in dialysis modality decision making., Conclusions and Call to Action: Many people with advanced kidney disease would prefer to have their dialysis at home, yet if the frail patient chooses PD most healthcare systems cannot provide their choice. AsPD should be available in all countries in Europe and in all renal centres. The top priorities to make this happen are education of renal healthcare teams about the advantages of PD, education of and discussion with patients and their families as they approach the need for dialysis, and engagement with policymakers and healthcare providers to develop and support assistance for PD., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Introduction: Surprisingly few studies have explored the experiences of seriously unwell people with kidney disease on hemodialysis therapy: we conducted a mixed-methods study to investigate gender differences in illness experience, symptom burden, treatment considerations or expectations in this cohort., Methods: Seriously unwell people on hemodialysis (1-year mortality risk of >20%) at 3 hospital-based units were invited to take part in a structured interview or to complete the same questions independently via a questionnaire. A total of 54 people took part (36 males, 18 females); data analysis was undertaken using a thematic approach., Results: "Desire to keep living" is the most important and basic thought process when starting dialysis. Fear also predominates influencing risk assessment and decision-making. Once fear is managed, there are physical, social, practical and emotional issues to rationalize, but choice only seems possible if shared decision-making is part of the consultation.Gender differences were seen in perceived hopes and expectations of treatment. Males were more likely to prioritize achievement of physical goals, with females prioritizing a wish to feel well. Both genders reported significantly higher symptom scores than their health care provider perceived, however this difference was more marked in females. Dialysis regret existed in >50% of participants and 6 out of 54 (11%) stated that they would have chosen no dialysis at all. Females were more likely to report feeling depressed ( P  = 0.001)., Conclusion: Different genders approach treatment decisions and prioritize treatment expectations differently. Recognizing this will allow personalized care plans to be developed and improve the experiences of seriously unwell people with kidney disease., (© 2022 International Society of Nephrology. Published by Elsevier Inc.)

Background: Kidney transplantation in older people has increased, however older transplant recipients experience mixed outcomes that invariably impacts on their quality of life. The increased vulnerability of older end stage kidney disease patients to frailty and cognitive impairment, may partially explain the differences in outcomes observed. The Kidney Transplantation in Older People (KTOP): impact of frailty on clinical outcomes study is an active clinical study aiming to explore the experience of older people waiting for and undergoing transplantation. In this manuscript we present the study protocol, the study cohort, and the prevalence of frailty and cognitive impairment identified at recruitment., Methods: The KTOP study is a single centre, prospective, mixed methods, observational study. Recruitment began in October 2019. All patients aged 60 or above either active on the deceased donor waitlist or undergoing live donor transplantation were eligible for recruitment. Recruited participants completed a series of questionnaires assessing frailty, cognition, and quality of life, which are repeated at defined time points whilst on the waitlist and post-transplant. Clinical data was concurrently collected. Any participants identified as frail or vulnerable were also eligible for enrolment into the qualitative sub-study., Results: Two hundred eight participants have been recruited (age 60-78). Baseline Montreal Cognitive Assessments were available for 173 participants, with 63 (36.4%) participants identified as having scores below normal (score < 26). Edmonton Frail Scale assessments were available for 184 participants, with 29 participants (15.8%) identified as frail (score ≥ 8), and a further 37 participants (20.1%) identified as being vulnerable (score 6-7)., Conclusion: In the KTOP study cohort we have identified a prevalence of 36.4% of participants with MoCA scores suggestive of cognitive impairment, and a prevalence of frailty of 15.8% at recruitment. A further 20.1% were vulnerable. As formal testing for cognition and frailty is not routinely incorporated into the work up of older people across many units, the presence and significance of these conditions is likely not known. Ultimately the KTOP study will report on how these parameters evolve over time and following a transplant, and describe their impact on quality of life and clinical outcomes., (© 2022. The Author(s).)

Background: The rapidly evolving novel coronavirus 2019 (COVID-19) pandemic bought many kidney transplant (KT) programs to a halt. Integral to resuming KT activity is understanding the perspectives of potential transplant candidates during this highly dynamic time., Methods: From June 1 to July 7, 2020, a telephone survey of KT candidates on the deceased donor waiting list at Imperial College Renal and Transplant Centre in West London was conducted. The survey captured ongoing COVID-19 exposure risks and patients' views on waitlist (WL) reactivation and undergoing transplantation., Results: Two hundred seven responses were received. Of the respondents, 180 patients (87%) were happy to be reactivated onto the WL; with 141 patients (68%) willing to give consent to transplantation currently, while 53 patients (26%) felt unsure, and 13 patients (6%) would decline a KT. The vast majority of patients had no concerns. In the responses from those who were uncertain or who would decline a KT, concerns about COVID-19 infection and the need for reassurance from transplant units dominated. Universally patients wanted more information about COVID-19 infection risk with KT and the precautions being taken to reduce this risk., Conclusions: The majority of surveyed patients are in favor of reactivation and receiving a KT despite the ongoing COVID-19 pandemic. Reactivation of candidates cannot be assumed and should take an individualized approach, incorporating clinical risk with patient perspectives. Improved communication with KT candidates is highly requested., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 The Author(s). Transplantation Direct. Published by Wolters Kluwer Health, Inc.)

Introduction: A better understanding of factors influencing perceived life expectancy (PLE), interactions between patient prognostic beliefs, experiences of illness, and treatment behavior is urgently needed., Methods: Case-notes at 3 hemodialysis units were screened: patients with ≥20% 1-year mortality risk were included. Patients and their health care professionals (HCPs) were invited to complete a structured interview or mixed-methods questionnaire. Four hundred eleven patient notes were screened. Seventy-seven eligible patients were approached and 51 were included., Results: Patients predicted significantly higher life expectancies than HCPs ( P  < 0.0001). Documented cognitive impairment, gender, or increasing age did not affect 1- or 5-year PLE. PLE influenced priorities of care: one-fifth of patients who estimated themselves to have >95% 1-year survival preferred "care focusing on relieving pain and discomfort," compared with nearly three-quarters of those reporting a ≤50% chance of 1-year survival. Twenty of 51 (39%) patients believed transplantation was an option for them, despite only 4 being waitlisted at the time of the interview. Patients who thought they were transplant candidates were significantly more confident they would be alive at 1 and 5 years and to want resuscitation attempted. Cognitive impairment had no effect on perceived transplant candidacy. A high symptom burden was present and underrecognized by HCPs. High symptom burden was associated with significantly lower PLE at both 1 and 5 years, increased anxiety/depression scores, and treatment choices more likely to prioritize relief of suffering., Conclusion: There is a disparity between patient PLE and those of their HCPs. Severity of symptom burden and beliefs regarding PLE or transplant candidacy affect patient treatment preferences., (© 2021 International Society of Nephrology. Published by Elsevier Inc.)

Background: Patient burnout is a major cause of technique failure on peritoneal dialysis (PD). Reducing the PD prescription on an individual basis, dependent upon residual kidney function (RKF), may have a role in prolonging time on PD by reducing dialysis burden. This retrospective study aimed to determine the safety and impact of flexible PD prescribing on technique and patient survival., Methods: All patients (186) from our centre starting PD from 1st January 2012 to 31st December 2016 were included. Data on dialysis prescription were collected for each patient from the time they had started PD, and dialysis adequacy measured regularly (3-6 monthly) using PD Adequest., Results: Median age at start of dialysis was 61 years. Only 49% started on PD 7 days a week and this dropped to 27% at 3 months following the first clearance test. Over 90% achieved creatinine clearance > 50 L/week/1.73 m 2 up to 2 years of follow-up, with 87% achieving this standard at 3 years. Patient and technique survival at 1, 2 and 3 years were 91%, 81%, and 72%, and 89%, 87% and 78% respectively. Factors on univariate analysis affecting technique survival included increasing age (HR 0.98, p = 0.04, 95% CI (0.96-0.999)), two or more episodes of PD-associated peritonitis (HR 4.52, p = 0.00, 95% CI (1.87-10.91)) and increasing PD intensity (HR 3.30, p = 0.02, 95% CI (1.22-8.93)). After multivariate adjustment which included baseline kidney function, low PD intensity continued to be associated with better technique survival (HR 0.17, p = 0.03, 95% CI (0.03-0.85))., Conclusion: Tailoring the PD prescription to RKF enables days off dialysis while still maintaining recommended levels of small solute clearance. This approach reduces dialysis burden and is associated with higher technique survival.

Background and Objectives: People with kidney failure typically receive KRT in the form of dialysis or transplantation. However, studies have suggested that not all patients with kidney failure are best suited for KRT. Additionally, KRT is costly and not always accessible in resource-restricted settings. Conservative kidney management is an alternate kidney failure therapy that focuses on symptom management, psychologic health, spiritual care, and family and social support. Despite the importance of conservative kidney management in kidney failure care, several barriers exist that affect its uptake and quality., Design, Setting, Participants, & Measurements: The Global Kidney Health Atlas is an ongoing initiative of the International Society of Nephrology that aims to monitor and evaluate the status of global kidney care worldwide. This study reports on findings from the 2018 Global Kidney Health Atlas survey, specifically addressing the availability, accessibility, and quality of conservative kidney management., Results: Respondents from 160 countries completed the survey, and 154 answered questions pertaining to conservative kidney management. Of these, 124 (81%) stated that conservative kidney management was available. Accessibility was low worldwide, particularly in low-income countries. Less than half of countries utilized multidisciplinary teams (46%); utilized shared decision making (32%); or provided psychologic, cultural, or spiritual support (36%). One-quarter provided relevant health care providers with training on conservative kidney management delivery., Conclusions: Overall, conservative kidney management is available in most countries; however, it is not optimally accessible or of the highest quality., (Copyright © 2021 by the American Society of Nephrology.)

Background: Randomized trials can provide evidence to inform decision-making but this may be limited if the outcomes of importance to patients and clinicians are omitted or reported inconsistently. We aimed to assess the scope and heterogeneity of outcomes reported in trials in peritoneal dialysis (PD)., Methods: We searched the Cochrane Kidney and Transplant Specialized Register for randomized trials in PD. We extracted all reported outcome domains and measurements and analyzed their frequency and characteristics., Results: From 128 reports of 120 included trials, 80 different outcome domains were reported. Overall, 39 (49%) domains were surrogate, 23 (29%) patient-reported and 18 (22%) clinical. The five most commonly reported domains were PD-related infection [59 (49%) trials], dialysis solute clearance [51 (42%)], kidney function [45 (38%)], protein metabolism [44 (37%)] and inflammatory markers/oxidative stress [42 (35%)]. Quality of life was reported infrequently (4% of trials). Only 14 (12%) trials included a patient-reported outcome as a primary outcome. The median number of outcome measures (defined as a different measurement, aggregation and metric) was 22 (interquartile range 13-37) per trial. PD-related infection was the most frequently reported clinical outcome as well as the most frequently stated primary outcome. A total of 383 different measures for infection were used, with 66 used more than once., Conclusions: Trials in PD include important clinical outcomes such as infection, but these are measured and reported inconsistently. Patient-reported outcomes are infrequently reported and nearly half of the domains were surrogate. Standardized outcomes for PD trials are required to improve efficiency and relevance., (© The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA.)

Premature muscle tiring (fatigue) is an important complication of advanced kidney disease, and results in a reduced ability to walk and exercise. As patients move from pre-dialysis care to dialysis, they begin to lose their residual kidney function and experience muscle wasting. Not all patients on dialysis are affected equally by the loss of muscle mass, and the effect of dialysis mode (peritoneal dialysis and hemodialysis) on muscle wasting is not known. This review will explore molecular mechanisms relevant to muscle wasting in end-stage kidney disease and in particular address some important insights into the emerging role of microRNAs in regulating the wasting response in individuals with chronic disease.

Background: Little is known about long-term survivors with encapsulating peritoneal sclerosis (EPS). Published literature focuses on patients managed surgically. We describe our experience of the long-term outcomes in patients with EPS conservatively managed with nutritional support alone., Methods: This is a single-centre retrospective observational study of patients who had survived for ≥ 5 years since diagnosis. EPS survivors were invited for review of symptoms, nutritional assessment and evaluation of quality of life. Radiological progression was assessed based on serial computed tomography (CT) scores for each patient., Results: A total of 23 patients with a diagnosis of EPS for at least 5 years were identified, with 18 patients alive at the time of the study. Of these 18 patients, 10 patients transferred to haemodialysis (HD) and 8 patients received kidney transplants. Commonest symptoms were nausea (91%) and vomiting (73%). Mean body mass index for patients was within the ideal and healthy range, with only 11% suffering from continued weight loss. In all, 70% EPS survivors on HD received nutritional support compared to 15% of those with transplants; 17% required ongoing parenteral nutrition. Of the 11 patients with serial CT scans at least 4 years apart, 10 had an increase in radiological score for EPS but with no apparent correlation to clinical outcomes. There were no significant differences in the reported quality of life between EPS survivors on HD and those transplanted, with self-rated health status equivalent to that reported for the general end-stage kidney disease (ESKD) population., Conclusion: Long-term survival following EPS managed conservatively with nutritional support is feasible, with the majority no longer requiring nutritional support and having a quality of life similar to other patients with ESKD.