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The COVID-19 pandemic has been particularly threatening to patients with end-stage kidney disease (ESKD) on intermittent hemodialysis and their care providers. Hemodialysis patients who receive life-sustaining medical therapy in healthcare settings, face unique challenges as they need to be at a dialysis unit three or more times a week, where they are confined to specific settings and tended to by dialysis nurses and staff with physical interaction and in close proximity. Despite the importance and critical situation of the dialysis units, modelling studies of the SARS-CoV-2 spread in these settings are very limited. In this paper, we have used a combination of discrete event and agent-based simulation models, to study the operations of a typical large dialysis unit and generate contact matrices to examine outbreak scenarios. We present the details of the contact matrix generation process and demonstrate how the simulation calculates a micro-scale contact matrix comprising the number and duration of contacts at a micro-scale time step. We have used the contacts matrix in an agent-based model to predict disease transmission under different scenarios. The results show that micro-simulation can be used to estimate contact matrices, which can be used effectively for disease modelling in dialysis and similar settings., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Plastic cannulas (PC) have shown efficacy in haemodialysis (HD) and are presented as a positive innovation for patients and vascular access survival., Objective: To analyse Spanish HD nurses' experience of using PC., Design: Cross-sectional observational study., Methods: An ad hoc questionnaire was administered on nurses' experience of PC use., Results: A total of 163 Spanish HD nurses were surveyed, of whom 42.3% had PC in their workplace and 50.9% had used them. In all, 55.8% had received training and 77.9% wished to receive more training. These needles were significantly more available in public institutions than in private centres (p < 0.001). There was no significant difference between years of experience and having received training (p = 0.915). There was a moderate-strong correlation (ρ = 0.659) between greater professional satisfaction with the product and greater patient satisfaction (p < 0.001). The nurses would make a median of two [P 25 , 1; P 75 , 3] modifications in the product design. The characteristics of the PC were rated positively by 55.8% and negatively by 10.3%., Conclusions: A substantial proportion of the nurses surveyed did not use PC and had not received training in their use. Respondents reported that PC could be improved and a small percentage perceived them negatively., Implications for Practice: Based on the evidence presented and available, if we manage to integrate this knowledge and work on the continuum of achieving excellence, we will continue to grow as a profession and provide higher quality care., (© 2020 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Background: Patients undergoing long-term dialysis may be at higher risk of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and of associated disease and mortality. We aimed to describe the incidence, risk factors and outcomes for infection in these patients in Ontario, Canada., Methods: We used linked data sets to compare disease characteristics and mortality between patients receiving long-term dialysis in Ontario who were diagnosed SARS-CoV-2 positive and those who did not acquire SARS-CoV-2 infection, between Mar. 12 and Aug. 20, 2020. We collected data on SARS-CoV-2 infection prospectively. We evaluated risk factors for infection and death using multivariable logistic regression analyses., Results: During the study period, 187 (1.5%) of 12 501 patients undergoing dialysis were diagnosed with SARS-CoV-2 infection. Of those with SARS-CoV-2 infection, 117 (62.6%) were admitted to hospital and the case fatality rate was 28.3%. Significant predictors of infection included in-centre hemodialysis versus home dialysis (odds ratio [OR] 2.54, 95% confidence interval [CI] 1.59-4.05), living in a long-term care residence (OR 7.67, 95% CI 5.30-11.11), living in the Greater Toronto Area (OR 3.27, 95% CI 2.21-4.80), Black ethnicity (OR 3.05, 95% CI 1.95-4.77), Indian subcontinent ethnicity (OR 1.70, 95% CI 1.02-2.81), other non-White ethnicities (OR 2.03, 95% CI 1.38-2.97) and lower income quintiles (OR 1.82, 95% CI 1.15-2.89)., Interpretation: Patients undergoing long-term dialysis are at increased risk of SARS-CoV-2 infection and death from coronavirus disease 2019. Special attention should be paid to addressing risk factors for infection, and these patients should be prioritized for vaccination., Competing Interests: Competing interests: Leena Taji, Doneal Thomas, Jane Ip, Yiwen Tang, Angie Yeung and Rebecca Cooper are salaried employees of Ontario Renal Network, Ontario Health. Matthew Oliver, Phil McFarlane and Peter Blake are contracted Medical Leads at Ontario Renal Network, Ontario Health. Matthew Oliver is owner of Oliver Medical Management Inc., which licenses Dialysis Management Analysis and Reporting System software. He has received honoraria for speaking from Baxter Healthcare and participated on Advisory Boards for Janssen and Amgen. Peter Blake has received honoraria from Baxter Global for speaking engagements. Andrew House has received honoraria from Baxter for speaking engagements. Phil McFarlane has received consultant or lecture fees from Amgen, Astra-Zeneca, Bayer, BMS, Boehringer-Ingelheim, GSK, Janssen, Lilly, Novartis, Otsuka, Sanofi-Aventis, Servier and Vifor. He has also received research grants from Amgen, Astra-Zeneca, Bayer, Boehringer-Ingelheim and Otsuka. No other competing interests were declared., (© 2021 Joule Inc. or its licensors.)

Our Nephrology and Dialysis Unit includes three Haemodialysis Centres based in Savona, Albenga and Cairo Montenotte. These provide assistance to 150 patients. We have a Peritoneal Dialysis Clinic with 35 patients, two Post-Transplant Clinics with about 120 patients in follow-up in Savona and Albenga, and three Pre-Dialysis Clinics across the three locations. Finally, there is an autonomous hospital ward with 15 beds that has continued its activity, even if at reduced regimes. With this report we intend to share the strategy we used to prevent the spread of the SARS CoV-2 virus among the patients and the staff at our Unit, following the National, Regional and Corporate guidelines published during "Phase 1". We decided that the Haemodialysis Centres needed to remain a safe place. To insure this, medical and nursing staff and patients had to behave conscientiously and collaboratively, and according to the official Hospital guidance. Our main concern was to protect patients who, despite suffering complications and being at high risk because of their age, immunodepression and multiple comorbidities, were forced to leave their house three times a week to be treated with dialysis. The results of this strategy have ensured that, of the 150 patients undergoing haemodialysis, only 3 have been tested positive: no patients in Albenga, 2 in Savona and 1 in Cairo Montenotte, all of them lived and were infected in their nursing homes. Also, there was no positivity among any of the staff members across the three locations. Our results are extremely positive and confirm the validity that prevention and protection procedures had in the earlier stages of the pandemic., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

Background: Novel coronavirus disease (COVID-19) is spreading rapidly, which poses great challenges to patients on maintenance hemodialysis. Here we report the clinical features of 66 hemodialysis patients with laboratory confirmed COVID-19 infection., Design, Setting, Participants, and Measurements: Retrospective, single-center case series of the 66 hemodialysis patients with confirmed COVID-19 from 1 January to 5 March 2020; the final date of follow-up was 25 March 2020., Results: The clinical data were collected from 66 hemodialysis patients with confirmed COVID-19. The incidence of COVID-19 in our center was 11.0% (66/602), of which 18 patients died. According to different prognosis, hemodialysis patients with COVID-19 were divided into the survival and death group. A higher incidence of fever and dyspnea was found in the death group compared with the survival group. Meanwhile, patients in the death group were often accompanied by higher white blood cell count, prolonged PT time, increased D-dimer ( p  < .05). More patients in the death group showed hepatocytes and cardiomyocytes damage. Furthermore, logistic regression analysis suggested that fever, dyspnea, and elevated D-dimer were independent risk factors for death in hemodialysis patients with COVID-19 (OR, 1.077; 95% CI, 1.014 to 1.439; p  = .044; OR, 1.146; 95% CI, 1.026 to 1.875; p  = .034, OR, 4.974; 95% CI, 3.315 to 6.263; p  = .007, respectively)., Conclusions: The potential risk factors of fever, dyspnea, and elevated D-dimer could help clinicians to identify hemodialysis patients with poor prognosis at an early stage of COVID-19 infection.

Rationale & Objective: Hemodialysis patients are at increased risk for coronavirus disease 2019 (COVID-19) transmission due in part to difficulty maintaining physical distancing. Our hemodialysis unit experienced a COVID-19 outbreak despite following symptom-based screening guidelines. We describe the course of the COVID-19 outbreak and the infection control measures taken for mitigation., Study Design: Retrospective cohort study., Setting & Participants: 237 maintenance hemodialysis patients and 93 hemodialysis staff at a single hemodialysis center in Toronto, Canada., Exposure: Universal screening of patients and staff for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)., Outcomes: The primary outcome was detection of SARS-CoV-2 in nasopharyngeal samples from patients and staff using reverse transcriptase-polymerase chain reaction (RT-PCR)., Analytical Approach: Descriptive statistics were used for clinical characteristics and the primary outcome., Results: 11 of 237 (4.6%) hemodialysis patients and 11 of 93 (12%) staff members had a positive RT-PCR test result for SARS-CoV-2. Among individuals testing positive, 12 of 22 (55%) were asymptomatic at time of testing and 7 of 22 (32%) were asymptomatic for the duration of follow-up. One patient was hospitalized at the time of SARS-CoV-2 infection and 4 additional patients with positive test results were subsequently hospitalized. 2 (18%) patients required admission to the intensive care unit. After 30 days' follow-up, no patients had died or required mechanical ventilation. No hemodialysis staff required hospitalization. Universal droplet and contact precautions were implemented during the outbreak. Hemodialysis staff with SARS-CoV-2 infection were placed on home quarantine regardless of symptom status. Patients with SARS-CoV-2 infection, including asymptomatic individuals, were treated with droplet and contact precautions until confirmation of negative SARS-CoV-2 RT-PCR test results. Analysis of the outbreak identified 2 index cases with subsequent nosocomial transmission within the dialysis unit and in shared shuttle buses to the hemodialysis unit., Limitations: Single-center study., Conclusions: Universal SARS-CoV-2 testing and universal droplet and contact precautions in the setting of an outbreak appeared to be effective in preventing further transmission., (Copyright © 2020 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Lombardy was violently hit by Covid-19 between the end of February and the beginning of March 2020. On 09.05.2020 there were 81225 total registered Covid-19+ cases (8051 / million inhabitants) with 14924 deaths (1479 deaths / million inhabitants). The province of Cremona presented a higher number of Covid-19+ cases and a worse relative mortality than the already high regional average. Patients on regular hemodialysis treatment present a high risk of infection due to the co-pathologies present, while healthcare workers may represent a risk for themselves and for the patients, due to the treatment environment and the close contact with them. All patients and healthcare workers of the Dialysis Center in Crema were evaluated (oro-pharyngeal swab for viral RNA research, qualitative anti-Covid-19 antibodies, quantitative IgG antibodies, co-pathologies), regardless of the symptomatology, over a 60-day period. Hemodialysis patients have a risk of infection that is 12.7 times that of the local population, while healthcare workers outperform the patients for Covid-positivity (30.3% vs 21.6%). Lethality in infected patients is high (31% of Covid-19+ subjects), while it is zero among healthcare professionals. The antibody response (qualitative and quantitative) in Covid-19+ patients is adequate, when compared to that of Covid-19+ healthcare staff. In our Center, the most critical phase lasted about 45 days but, thanks to the measures taken, it was possible to make the dialysis area Covid-free, as it remains after 128 days.

We report the brief experience of the Nephrology Center located in a "no-COVID" Hospital in Massa Marittima. We describe the actions taken to prevent the transmission of the virus SARS-CoV-2 among hemodialysis patients and healthcare workers and the methods for diagnosing COVID-19, with particular attention to serological tests and nasopharyngeal swabs in asymptomatic subjects. The detection of IgM and IgG antibodies through the serological test performed on 34 patients, all negative for nasopharyngeal swabs, showed positivity in 41,18% of cases. These have been classified as false positives following repeated negative nasopharyngeal swabs, the evaluation of clinical and epidemiological history and of clinical manifestations and, finally, a second serological test performed after 18 days, which resulted negative for all patients. Interpreting serological tests is not easy; the strategies for diagnosis should include clinical and epidemiological history and clinical manifestations, as well as the results of confirmation tests and the evaluation over a precise observation period. Otherwise, there is a risk of considering as protected by antibodies subjects that are in fact false positives., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

The epidemic wave that hit Italy from February 21st, 2020, when the Italian National Institute of Health confirmed the first case of SARS‑CoV‑2 infection, led to a rapid and efficient reorganization of Dialysis Centers' activities, in order to contain large-scale spread of disease in this clinical setting. We herein report the experience of the Hemodialysis Unit of Parma University Hospital (Azienda Ospedaliero-Universitaria, Parma, Italy) and the Dialysis Centers of Parma territory, in the period from March 1st, 2020 to June 15, 2020. Among patients undergoing chronic haemodialysis, 37/283 (13%) had positive swabs for SARS‑CoV‑2, 9/37 (24%) died because of COVID-19. Twenty-three patients required hospitalization, while the remaining were managed at home. The primary measures applied to contain the infection were: the strengthening of personal protective equipment use by doctors and nurses, early identification of infected subjects by performing oro-pharyngeal swabs in every patient and in the healthcare personnel, the institution of a triage protocol when entering Dialysis Room, and finally the institution of two separate sections, managed by different doctors and dialysis nurses, to physically separate affected from unaffected patients and to manage "grey" patients. Our experience highlights the importance and effectiveness of afore-mentioned measures in order to contain the spread of the virus; moreover, we observed a higher lethality rate of COVID-19 in dialysis patients as compared to the general population., (Copyright by Società Italiana di Nefrologia SIN, Rome, Italy.)

Aims: To examine the prevalence of diabetic chronic kidney disease (DCKD) and its risk factors in adult Greek subjects with type 2 diabetes mellitus (T2DM) in a population from hospital-based diabetes clinics., Methods: This is a cross-sectional multicentre study based on data collected from Greek hospital-based diabetes clinics from June 2015 to March 2016. DCKD severity was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 guidelines. Multivariate analyses assessed the associations between DCKD and its potential risk factors., Results: Among the entire population (n = 1759), the overall prevalence of DCKD was 45% including mild, moderate and severe CKD. Older age, male gender, body-mass index, lack of exercise and diabetes duration were significantly associated with DCKD., Conclusions: In Greece, DCKD in T2DM is highly prevalent. It is significantly associated with demographic and lifestyle parameters, as well as T2DM complications, suggesting that further efforts to prevent DCKD should be addressed to subjects with specific characteristics., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Rationale & Objective: Patients with multiple comorbid conditions are less likely to use an arteriovenous fistula (AVF) for hemodialysis vascular access. Some dialysis facilities have high rates of AVF placement despite having patients with many comorbid conditions. This study describes variation in facility-level use of AVFs across the facility-level burden of patient comorbid conditions., Study Design: Retrospective cohort study., Setting & Participants: Medicare patients receiving hemodialysis for 1 year or more in US dialysis facilities., Predictors: Facility-level burden of patient comorbid conditions; patient characteristics., Outcomes: Odds of AVFs versus other access types; facility-level use of AVFs., Analytical Approach: Facility-level comorbidity burden was calculated by summing individual comorbid conditions, determining the average per patient, then defining 11 groups based on facility percentile ranking. Generalized estimating equations with a logit link were used to estimate the odds of AVF placement at the patient level. For the facility-level analysis, a generalized estimating equation model with the identity link was fit to characterize the percentage of AVF use at each facility., Results: Overall, AVF use was 65.8% in 315,919 prevalent hemodialysis patients among 5,813 facilities. After adjustment for patient characteristics, AVF use was 0.27, 0.30, 1.05, and 1.74 percentage points lower than the median among facilities in the 61st to 70th, 71st to 80th, 81st to 90th, and 91st to 99th percentiles of comorbidity, respectively, and 0.42, 0.63, 1.34, and 1.90 percentage points higher than the median among facilities in the 31st to 40th, 21st to 30th, 11th to 20th, and 1st to 10th percentiles of comorbidity, respectively. Facilities in the greater than 99th percentile of comorbidity burden had AVF use that was 3.47 percentage points lower than the median. Facilities in the less than 1st percentile of comorbidity burden had AVF use that was 2.64 percentage points greater than the median., Limitations: Limited to Medicare dialysis-dependent patients treated for 1 year or more., Conclusions: After adjustment for patient characteristics, we found small differences in facility rates of AVF use except in the extremes of high or low levels of comorbidity burden. Our study demonstrates that dialysis facilities with a relatively high patient comorbidity burden can achieve similar fistula rates as facilities with healthier patients. Although high comorbidity burden does not explain low facility AVF use, additional study is needed to understand differences in AVF use rates between facilities with similar comorbidity burdens., (Copyright © 2019 National Kidney Foundation, Inc. All rights reserved.)

Introduction: The recent appearance of the SARS-CoV-2 coronavirus pandemic has had a significant impact on the general population. Patients on renal replacement therapy (RRT) have not been unaware of this situation and due to their characteristics they are especially vulnerable. We present the results of the analysis of the COVID-19 Registry of the Spanish Society of Nephrology., Material and Methods: The Registry began operating on March 18th, 2020. It collects epidemiological variables, contagion and diagnosis data, signs and symptoms, treatments and outcomes. It is an online registry. Patients were diagnosed with SARS-CoV-2 infection based on the results of the PCR of the virus, carried out both in patients who had manifested compatible symptoms or had suspicious signs, as well as in those who had undergone screening after some contact acquainted with another patient., Results: As of April 11, the Registry had data on 868 patients, from all the Autonomous Communities. The most represented form of RRT is in-center hemodialysis (ICH) followed by transplant patients. Symptoms are similar to the general population. A very high percentage (85%) required hospital admission, 8% in intensive care units. The most used treatments were hydroxychloroquine, lopinavir-ritonavir, and steroids. Mortality is high and reaches 23%; deceased patients were more frequently on ICH, developed pneumonia more frequently, and received less frequently lopinavir-ritonavir and steroids. Age and pneumonia were independently associated with the risk of death., Conclusions: SARS-CoV-2 infection already affects a significant number of Spanish patients on RRT, mainly those on ICH, hospitalization rates are very high and mortality is high; age and the development of pneumonia are factors associated with mortality., (Copyright © 2020 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Dialysis patients are a risk group for SARS-CoV-2 infection and possibly further complications, but we have little information. The aim of this paper is to describe the experience of the first month of the SARS-CoV-2 pandemic in a hospital haemodialysis (HD) unit serving the district of Madrid with the second highest incidence of COVID-19 (almost 1,000 patients in 100,000h). In the form of a diary, we present the actions undertaken, the incidence of COVID-19 in patients and health staff, some clinical characteristics and the results of screening all the patients in the unit. We started with 90 patients on HD: 37 (41.1%) had COVID-19, of whom 17 (45.9%) were diagnosed through symptoms detected in triage or during the session, and 15 (40.5%) through subsequent screening of those who, until that time, had not undergone SARS-CoV-2 PCR testing. Fever was the most frequent symptom, 50% had lymphopenia and 18.4% <95% O 2 saturation. Sixteen (43.2%) patients required hospital admission and 6 (16.2%) died. We found a cluster of infection per shift and also among those using public transport. In terms of staff, of the 44 people involved, 15 (34%) had compatible symptoms, 4 (9%) were confirmed as SARS-CoV-2 PCR cases by occupational health, 9 (20%) required some period of sick leave, temporary disability to work (ILT), and 5 were considered likely cases. CONCLUSIONS: We detected a high prevalence of COVID-19 with a high percentage detected by screening; hence the need for proactive diagnosis to stop the pandemic. Most cases are managed as outpatients, however severe symptoms are also appearing and mortality to date is 16.2%. In terms of staff, 20% have required sick leave in relation to COVID-19., (Copyright © 2020 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: In 2011, inclusion of injectable medications into an expanded ESKD payment bundle prompted concerns that dialysis facilities facing higher costs might close, disrupting care delivery and access to care. Whether this policy change influenced dialysis facility closures is unknown., Methods: To examine whether facility closures increased after 2011 and whether factors influencing closures changed, we analyzed US Renal Data System registry data to identify all patients receiving in-center hemodialysis from 2006 through 2015 and to track dialysis facility closures. We used interrupted time series logistic regression models and estimated marginal effects to examine immediate and longer-term changes in the likelihood of being affected by facility closures following payment reform. We also examined whether associations between selected predictors of closures indicating populations at "high risk" of closure (patient characteristics, facility characteristics, and geography-related characteristics) and closures changed after payment reform., Results: Dialysis facility closures were uncommon over the study period. In adjusted models, the relative odds of experiencing a closure declined by 37% (odds ratio [OR], 0.63; 95% confidence interval [95% CI], 0.59 to 0.67) immediately after payment reform and declined by an additional 6% (OR, 0.94; 95% CI, 0.91 to 0.97) annually thereafter, corresponding to a 0.3% lower absolute probability of closure in 2015 in association with payment reform. Patients who were black and who dialyzed at small, hospital-based facilities experienced slight increases in closures following payment reform, whereas Hispanic and Medicare/Medicaid dual-eligible patients experienced slight decreases in closures., Conclusions: Expansion of the ESKD payment bundle was not associated with increased closure of dialysis facilities, although the likelihood of closures changed slightly for some higher-risk populations., (Copyright © 2020 by the American Society of Nephrology.)

Objectives: To investigate the risk factors associated with early-onset peritonitis (EOP) and their influence on patients' technique survival and mortality., Study Design: Retrospective, cohort study., Setting: Three peritoneal dialysis (PD) units in Shanghai., Participants: PD patients from 1 June 2006 to 1 May 2018 were recruited and followed up until 31 December 2018. According to time-to-first episode of peritonitis, patients were divided into non-peritonitis (n=144), EOP (≤6 months, n=74) and late-onset peritonitis (LOP) (>6 months, n=139)., Primary and Secondary Outcome Measures: EOP was defined as the first episode of peritonitis occurring within 6 months after the initiation of PD. The outcomes were all-cause mortality and technique failure., Results: Of the 357 patients, 74 (20.7%) patients developed their first episode of peritonitis within the first 6 months. Compared with the LOP group, the EOP group had older ages, more female patients, higher Charlson Comorbidity Index (CCI) score, lower serum albumin levels and renal function at the time of initiation of PD, and higher diabetes mellitus and peritonitis rates (p<0.05). Staphylococcus was the most common Gram-positive organism in both EOP and LOP groups. The multivariate logistic regression analysis showed that factors associated with EOP included a higher CCI score (OR 1.285, p=0.011), lower serum albumin level (OR 0.924, p=0.016) and lower Kt/V (OR 0.600, p=0.018) at start of PD. In the Cox proportional-hazards model, EOP was more likely a predictor of technique failure (HR 1.801, p=0.051). There was no difference between EOP and LOP for all-cause mortality., Conclusion: A higher CCI score and lower serum albumin level and Kt/V at PD initiation were significantly associated with EOP. EOP also predicted a high peritonitis rate and poor clinical outcome., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The Guatemalan Foundation for Children with Kidney Diseases was established in 2003 as the first and only comprehensive pediatric nephrology program and hemodialysis unit in Guatemala. Bridge of Life (BOL) is a not-for-profit charitable organization focused on chronic kidney disease and supplied equipment, training and support during formation of the hemodialysis unit. Pediatric permanent vascular access (VA) expertise had not been established and noncuffed dialysis catheters provided almost all VA, many through subclavian vein access sites. BOL assistance was requested for establishing a VA surgical program, resulting in recurring BOL surgical missions to create arteriovenous fistulas (AVF) in these children. This study analyzes the BOL pediatric VA missions to Guatemala., Methods: Three surgical pediatric VA missions were conducted in Guatemala from 2015 to 2017. Each mission was led by two or three surgeons. All supplies and equipment (including ultrasound units) were taken as part of each mission. The BOL surgical VA mission teams work with local pediatric surgeons, pediatric nephrologists, and dialysis nurses to establish collegial relationships and foster teaching interactions. We retrospectively reviewed the patient demographic data, procedures, and outcomes for these missions., Results: AVFs were created in 54 new pediatric patients. Ages were 8 to 19 years (13.4 ± 2.8 years) and 29 patients (54%) were male. Patient weights were 28 to 50 kg (30.8 ± 8.3 kg) with body mass indexes of 12 to 25 kg/m 2 (17.9 ± 2.9 kg/m 2 ). Radiocephalic AVFs were created in 21 children (39%), proximal radial artery AVFs in 12 (22%). and brachial artery inflow AVFs in 5 (9%). Sixteen patients (30%) required transpositions and one a translocation; two of these were femoral procedures. Primary and cumulative patency rates were 83% and 85% at 12 months and 62% and 85% at 36 months, respectively. The median follow-up was 17 months. Interventions with fistulagram and balloon angioplasty options were not available for AVF dysfunction or access salvage during the study period. However, six patients underwent an AVF revision and salvage during subsequent missions or by one of the Guatemalan surgeons (R.S.). Four individuals underwent successful transplantation during the study period. There were no operative deaths or major complications., Conclusions: Pediatric VA missions to Guatemala created safe and functional AVFs in concert with local pediatric surgeons and pediatric nephrologists. Three surgical missions included access operations in 54 new patients. Cumulative AVF patency was 85% at 36 months., (Copyright © 2019 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Renal replacement therapy in India is predominantly a private health-care-driven initiative making it an expensive treatment option due to high out-of-pocket expenditures. Moreover, with the rapid increase in the number of chronic kidney disease patients requiring dialysis, hemodialysis units (HDUs) are getting saturated. Community "stand-alone" dialysis centers could be an important alternative to HDUs in meeting the growing demand in an affordable model. The aim of this study was to find hemodialysis (HD) delivery in "stand-alone" dialysis units (SAUs) with respect to expanding coverage, patient costs, and patient safety safeguards. The total number of HD sessions was collected at three points. The information regarding patient safety safeguards at SAUs and impact of SAUs on patient costs were collected by interviews and from hospital records. There was 11.5 times increase in HD sessions from 2008 to 2017, out of which 75.3% was provided at SAUs. Following objective clinical and safety measures, high-quality dialysis was delivered at SAUs and it significantly reduced the mean patient cost of treatment per session., Competing Interests: None

Background: The survival rate for dialysis patients is poor. Previous studies have shown improved survival with home hemodialysis (HHD), but this could be due to patient selection, since HHD patients tend to be younger and healthier. The aim of the present study is to analyse the long-term effects of HHD on patient survival and on subsequent renal transplantation, compared with institutional hemodialysis (IHD) and peritoneal dialysis (PD), taking age and comorbidity into account., Methods: Patients starting HHD as initial renal replacement therapy (RRT) were matched with patients on IHD or PD, according to gender, age, Charlson Comorbidity Index and start date of RRT, using the Swedish Renal Registry from 1991 to 2012. Survival analyses were performed as intention-to-treat (disregarding changes in RRT) and per-protocol (as on initial RRT)., Results: A total of 152 patients with HHD as initial RRT were matched with 608 IHD and 456 PD patients, respectively. Median survival was longer for HHD in intention-to-treat analyses: 18.5 years compared with 11.9 for IHD (p <  0.001) and 15.0 for PD (p = 0.002). The difference remained significant in per-protocol analyses omitting the contribution of subsequent transplantation. Patients on HHD were more likely to receive a renal transplant compared with IHD and PD, although treatment modality did not affect subsequent graft survival (p > 0.05)., Conclusion: HHD as initial RRT showed improved long-term patient survival compared with IHD and PD. This survival advantage persisted after matching and adjusting for a higher transplantation rate. Dialysis modality had no impact on subsequent graft survival.

Background: Health-related quality of life (HrQoL) varies among dialysis patients. However, little is known about the association of dialysis modality with HrQoL over time. We describe longitudinal patterns of HrQoL among chronic dialysis patients by treatment modality., Methods: National retrospective cohort study of adult patients who initiated in-center dialysis or a home modality (peritoneal or home hemodialysis) between 1/2013 and 6/2015. Patients remained on the same modality for the first 120 days of the first two years. HrQoL was assessed by the Kidney Disease and Quality of Life-36 (KDQOL) survey in the first 120 days of the first two years after dialysis initiation. Home modality patients were matched to in-center patients in a 1:5 fashion., Results: In-center (n=4234) and home modality (n=880) patients had similar demographic and clinical characteristics. In-center dialysis patients had lower mean KDQOL scores across several domains compared to home modality patients. For patients who remained on the same modality, there was no change in HrQoL. However, there were trends towards clinically meaningful changes in several aspects of HrQoL for patients who switched modalities. Specifically, physical functioning decreased for patients who switched from home to in-center dialysis (p< 0.05)., Conclusions: Among a national cohort of chronic dialysis patients, there was a trend towards different patterns of HrQoL life that were only observed among patients who changed modality. Patients who switched from home to in-center modalities had significant lower physical functioning over time. Providers and patients should be mindful of HrQoL changes that may occur with dialysis modality change.

Objective: to analyze the mean direct cost of the constituent procedures of conventional hemodialysis, performed in three public teaching and research hospitals., Method: quantitative, exploratory-descriptive study, of the multiple case study type. The mean direct cost was calculated by multiplying the time (timed) spent by nursing professionals, on the execution of procedures, by the unit cost of direct labor, added to the cost of materials and solutions/medications., Results: the total mean direct cost, in patients with an arteriovenous fistula corresponded to US$25.10 in hospital A, US$37.34 in hospital B and US$25.01 in hospital C, and in patients with a dual lumen catheter, US$32.07 in hospital A, US$40.58 in hospital B and US$30.35 in hospital C. The weighted mean values obtained were US$26.59 for hospital A, US$38.96 for hospital B and US$27.68 for hospital C. It was noted that the "installation and removal of hemodialysis fistula access" caused a significantly lower economic impact compared to "installation and removal of hemodialysis catheter access"., Conclusion: with the knowledge developed it will be possible to support hospital managers, technical managers and nursing professionals in the decision making process, with a view to the rational allocation of the necessary inputs for the performance of conventional hemodialysis.

Objective: To analyze variation in medical care use attributable to Medicare's decentralized claims adjudication process as exemplified in home hemodialysis (HHD) therapy., Data Sources/study Setting: Secondary data analysis using 2009-2012 paid Medicare claims for HHD and in-center hemodialysis (IHD)., Study Design: We compared variation across Medicare administrative contractors (MACs) in predicted paid treatments per standardized patient-month for HHD and IHD patients. We used ordinary least-squares regression to determine whether higher paid HHD treatment counts expanded HHD programs' presence among dialysis facilities., Data Collection: We identified HHD and IHD treatments using procedure, revenue center, and claim condition codes on type 72x claims., Principal Findings: MACs varied persistently in predicted HHD treatments per patient-month, ranging from 14.3 to 21.9 treatments versus 10.9 to 12.4 IHD treatments. The presence of facilities' HHD programs was uncorrelated with average HHD payment counts., Conclusions: Medicare's claims adjudication process promotes variation in medical care use, as we observe among HHD patients. MACs' discretionary decision making, while potentially facilitating innovation, may admit inefficiency in care practice as well as inequitable access to health care services. Regulators should weigh the benefits of flexibility in local coverage decisions against those of national standards for medical necessity., (© Health Research and Educational Trust.)

Background: Haemodialysis (HD) patients are a high-risk population group. For these patients, an error could have catastrophic consequences. Therefore, systems that ensure the safety of these patients in an environment with high technology and great interaction of the human factor is a requirement., Objectives: To show a systematic working approach, reproducible in any HD unit, which consists of recording the complications and errors that occurred during the HD session; defining which of those complications could be considered adverse event (AE), and therefore preventable; and carrying out a systematic analysis of them, as well as of underlying real or potential errors, evaluating their severity, frequency and detection; as well as establishing priorities for action (Failure Mode and Effects Analysis system [FMEA systems])., Methods: Retrospective analysis of the graphs of all HD sessions performed during one month (October 2015) on 97 patients, analysing all recorded complications. The consideration of these complications as AEs was based on a consensus among 13 health professionals and 2 patients. The severity, frequency and detection of each AE was evaluated by the FMEA system., Results: We analysed 1303 HD treatments in 97 patients. A total of 383 complications (1 every 3.4 HD treatments) were recorded. Approximately 87.9% of them was deemed AEs and 23.7% complications related with patients' underlying pathology. There was one AE every 3.8 HD treatments. Hypertension and hypotension were the most frequent AEs (42.7 and 27.5% of all AEs recorded, respectively). Vascular-access related AEs were one every 68.5 HD treatments. A total of 21 errors (1 every 62 HD treatments), mainly related to the HD technique and to the administration of prescribed medication, were registered. The highest risk priority number, according to the FMEA, corresponded to errors related to patient body weight; dysfunction/rupture of the catheter; and needle extravasation., Conclusions: HD complications are frequent. Consideration of some of them as AEs could improve safety by facilitating the implementation of preventive measures. The application of the FMEA system allows stratifying real and potential errors in dialysis units and acting with the appropriate degree of urgency, developing and implementing the necessary preventive and improvement measures., (Copyright © 2017 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Aim: There remains debate on which dialysis modality offers better survival outcomes for patients. We compare the survival of patients undergoing home haemodialysis (HD) with a permanent vascular access, facility HD with a permanent vascular access, facility HD with a central venous catheter or peritoneal dialysis., Methods: We considered adult patients from the Australia and New Zealand Dialysis and Transplant Registry who commenced dialysis between 1 October 2003 and 31 December 2011. Patients were followed until death, transplant, loss to follow-up or 31 December 2011. Marginal structural models for mortality were used to account for time-varying treatment, comorbidities and baseline covariates. Unmeasured differences between treatment groups may remain even after adjustment for measured differences, so the potential effects of unmeasured confounding were explicitly modelled., Results: There were 20,191 patients who underwent ≥90 days of dialysis (median 2.25 years, interquartile range 1-3.75 years). There were significant differences in age, gender, comorbidities and other variables between treatment groups at baseline. Thirty per cent of patients had at least one treatment change. Relative to facility HD with permanent access, the risk of death for home HD patients with a permanent access was lower in the first year (at 9 months: hazard ratio 0.41, 95% CI 0.25-0.67, adjusted for all baseline covariates). Findings were robust to unmeasured confounding within plausible ranges., Conclusion: Relative to facility HD with permanent vascular access, home HD conferred better survival prospects, while peritoneal dialysis was associated with a higher risk and facility HD with a catheter the highest risk, especially within the first year of dialysis., (© 2015 Asian Pacific Society of Nephrology.)

Background: Given the public health challenge and burden of chronic kidney disease, the Italian Society of Nephrology (SIN) promoted acensusof the renal and dialysis units to analyse structural and human resources, organizational aspects, activities and workload referring to theyear 2014., Methods: An online questionnaire, including 64 items exploring structural and human resources, organization aspects, activities and epidemiological data referred to 2014, was sent to chiefs of any renal or dialysis unit., Results: Renal and dialysis activity was performed by over 2718 physicians (45 pmp). The management of the acute renal failure was one of the most frequent activities in the public renal units (12,206 patients in ICU and 140.00 dialysis sessions). There were performed about 9000 AV fistulas and 1700 central vascular catheters insertions. In the census, there are a lot of data regarding organization, workforce and workload of the renal unit in Italy. The benchmark data derived from this census show interesting comparisons between centres, regions and groups of regions. These data realised the clinical management of renal disease in Italy.

Background: The Southeastern Kidney Transplant Coalition was created in 2010 to improve kidney transplant (KTx) rates in Georgia, North Carolina, and South Carolina. To identify dialysis staff-reported barriers to transplant, the Coalition developed a survey of dialysis providers in the region., Methods: All dialysis units in the ESRD Network (n = 586) were sent a survey to be completed by the professional responsible for helping patients get transplants., Results: One staff member at almost all (n = 546) of the dialysis units in Network 6 completed the survey (93% response rate). Almost all respondents reported being very comfortable (51.47%) or comfortable (46.89%) discussing the KTx process with patients. Just over half (56%) of facilities reported discussing KTx as a treatment option with patients on an annual basis. Fewer than one quarter of respondents (19%) perceived that more than 50% of their patients were interested in kidney transplant, and most of the staff surveyed (68%) reported that <25% of their dialysis patients completed the evaluation process and been wait-listed for a kidney transplant., Conclusion: The survey results provide insight into KTx referral practices in southeastern dialysis units that may be contributing to low KTx rates in this region., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

The number of older adults worldwide is increasing as societies gain success in improving the health and lifespan of their citizens. As a result, increasing numbers of older adults are presenting to the medical community with advanced kidney failure. Historically, dialysis treatments were withheld from older adults particularly those with severe co-existing illnesses. This has changed in most parts of the world, and there is now an increasing emphasis on shared decision-making to determine whether dialysis is appropriate and to determine which modality meets the needs, expectations, and desire of patients. Evidence examining the difference in risk for death of older adults treated with hemodialysis (HD) or peritoneal dialysis (PD), and the probability of those treated with PD to transfer to HD among older compared to younger adults, is largely derived from prospective cohort studies or analyses of data from national registries. In such studies, it is difficult to distinguish whether differences in outcomes reflect the effect of dialysis modality or differences in health status of different groups of patients. Longevity and technique survival are important, albeit not the only or most important consideration in such decision-making. Given the risk for bias in observational studies and the profound effect of dialysis modality on patients' lifestyle, the selection of dialysis modality should remain a decision made by the patient, caregivers, and his/her physician after thorough education and review of the available data., (Copyright © 2015 International Society for Peritoneal Dialysis.)

Nurses who work in hemodialysis (HD) are considered highly susceptible to burnout due to their close relationship with incurable patients and handling sophisticated machinery. A total of 210 nurses from 12 state-owned HD centers in the Republic of Serbia anonymously completed a background information questionnaire providingfactual data on nurses' sociodemographic characteristics and working conditions using the Maslach Burnout Inventory--Health Services Survey. Almost half of the nurses (42.9%) were experiencing burnout High emotional exhaustion, high depersonalization, and low level of personal accomplishment were present in 40.9%, 8.6%, and 31.3% of nurses, respectively. The number of children, involuntary choice of current position, and unwillingness to choose the same type of job again were significant predictors of burnout. Our population of nurses working in HD was more affected by emotional exhaustion than their colleagues in other countries, but maintained high level of empathy and feeling ofpersonal accomplishment.

Background: Aggression on haemodialysis units is a growing problem internationally that has received little research attention to date. Aggressive behaviour by patients or their relatives can compromise the safety and well-being of staff and other patients sharing a haemodialysis session., Objectives: The objectives of the study were twofold: First, to identify the prevalance and nature of aggression on haemodialysis units; and second, to investigate factors that contribute to aggressive behaviour on haemodialysis units., Design and Methods: A cross-sectional, sequential mixed method research design was adopted, with two research methods utilised. Incidents of aggressive behaviour were recorded over a 12-month period, using a renal version of the Staff Observation Aggression Scale. Six months after the incident data collection had commenced, semi-structured qualitative interviews were conducted with 29 multidisciplinary members of staff., Results: Over 12 months, 74 aggressive incidents were recorded. The majority of incidents involved verbal aggression, and the perpetrators were a minority of patients, relatives and staff. Two patients were responsible for 38% of all incidents; both patients had mental health problems. Distinct temporal patterns to the aggressive behaviour were observed according to the day of the week and time of day., Conclusion: This study demonstrates that aggression is a significant problem on haemodialysis units, with verbal aggression most prevalent. The temporal patterns to aggression observed are related to the uniqueness of the haemodialysis setting, with a distinctly different treatment environment compared with other healthcare settings., (© 2014 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Background: Previous studies have found significant stressors experienced by nurses working in hemodialysis units. The purpose of this study was to determine the burnout levels of hemodialysis nurses working in hemodialysis units and their relation with some sociodemographic variables., Methods: The study was conducted between July 2012 and Sept 2012 in hemodialysis units of four hospitals, including one university, one public and two private hospitals, in the province of Erzurum. The population of the study consisted of 32 nurses rendering service in hemodialysis units of the related hospitals. Information forms, which were prepared by researchers in accordance with the literature, and aimed at determining the personal characteristics of nurses and Maslach Burnout Inventory were used for the data collection., Results: Examining mean scores obtained by nurses from the Maslach Burnout Inventory, it is observed that they scored 17.07 ± 8.29 from subscale of emotional exhaustion, 5.89 ± 4.13 from subscale of depersonalization and 20.64 ± 4.10 from subscale of personal accomplishment., Conclusion: The results of the study revealed that nurses working in hemodialysis units experience a medium-level burnout in terms of subscales of emotional exhaustion, depersonalization, and a high-level burnout in terms of the subscale of personal accomplishment.

Purpose: Patient-reported outcomes are important endpoints to evaluate new models of renal delivery. This is the first study to compare Quality of Life (QOL) and emotional adjustment outcomes between patients on community-based hemodialysis (HD) and those on peritoneal dialysis (PD)., Methods: Data were collected between 2009 and 2011 from a cross-sectional sample of 232 HD patients and 201 PD patients recruited through community dialysis centers and outpatient PD clinics in Singapore. Participants completed the Hospital Anxiety and Depression Scale, World Health Organization Quality of Life Brief and the Short form for the Kidney Disease Quality of Life. Measures of ESRD severity, comorbidity and biochemistry were also collected., Results: Physical and emotional QOL impairments were noted for both dialysis groups. Case-mix-adjusted comparisons indicated higher symptoms of depression (p = 0.027), and poorer physical health yet higher satisfaction with care (p = 0.001) in PD relative to community-based HD., Conclusions: Peritoneal dialysis regimes offer flexibility and autonomy under the support of PD teams. Although outcomes for most QOL domains measured were equivalent, PD patients are more satisfied with care but are at risk for emotional distress and provide poor ratings of physical health. Further research is needed to explore the expansion of standards of care to address psychosocial needs in PD populations.

For patients with chronic renal failure (CRF), kidney transplant (KT) is a better alternative to dialysis in terms of survival, life quality and costs. We studied the general characteristics, causes and survival rate of the dialysis population in 2010. We evaluated broader criteria for acceptance of transplants has affected the results of the procedure in that period. A total of 118 dialysis patients were included; mean age 56.9 ± 18.4 years, dialysis duration 45.5 ± 59.6 months, main cause of CRF was diabetes in 35 (30%), and 58 (49%) were included in waiting list for KT. Of the 34 patients who finished dialysis in 2010, 18 (53%) were KT, while 12 (35%) died (cardiovascular 50%, infectious 17%). Survival at 12 months was 85% for the total group, 98% on waiting list and 72% those who were not enrolled. During 2010 there were 88 KT, 62 with cadaveric donors (CD), 18 with living donors and 8 with double pancreas-kidney transplants. Recipients of CD were 50.7 years old, with 67 months on dialysis, 8 (13%) diabetics, and 12 (20%) with previous KT. Donors had a mean age of 45 years, 28 (45%) expanded criteria, and 27.7 hours of cold ischemia time. During an approximate follow-up of 11.4 months, 13 (21%) suffered acute graft rejection, survival was 88% for graft and 93% for patients. We emphasize KT as the main cause of success as regards dialysis. No differences in risk factors were found to significantly affect graft or patient survival.

The association between dialysis facility size and mortality for patients undergoing hemodialysis remains largely unclear, and whether the relationship differs by race and ethnicity or among high-risk subgroups is not known. Using data from the USRDS, we analyzed mortality rates in 385,074 incident patients ages ≥ 18 years who received in-center hemodialysis at 4633 dialysis facilities between 2003 and 2009. Facilities were categorized by the number of hemodialysis stations (1-5, 6-10, 11-15, 16-20, 21-25, 26-30, 31-35, 36-45, 46-60, and ≥ 61 stations). We found significantly higher mortality associated with facilities comprising ≤ 15 stations, and within this group, mortality increased as the number of stations decreased. The association with increased mortality was weaker for facilities with 16-30 stations, but >30 stations offered no additional survival benefit. The association between increased mortality and facilities with ≤ 15 stations was stronger for racial minorities and patients with diabetes or cardiovascular diseases. After adjustments, blacks had a 78% greater 1-year mortality risk in facilities with one to five stations, whereas whites had only a 26% greater risk. Notably, other patient-related events remained comparable across the categories assessed. In summary, these data suggest that hemodialysis care at small facilities associates with a significant increase in mortality that is only partially explained by measured patient case mix, other well defined facility characteristics, and geographic region. Future studies should investigate differences in processes of care and practices among hemodialysis facilities of different sizes.

Motivated by the national evaluation of readmission rates among kidney dialysis facilities in the United States, we evaluate the impact of including discharging hospitals on the estimation of facility-level standardized readmission ratios (SRRs). The estimation of SRRs consists of two steps. First, we model the dependence of readmission events on facilities and patient-level characteristics, with or without an adjustment for discharging hospitals. Second, using results from the models, standardization is achieved by computing the ratio of the number of observed events to the number of expected events assuming a population norm and given the case-mix in that facility. A challenging aspect of our motivating example is that the number of parameters is very large and estimation of high-dimensional parameters is troublesome. To solve this problem, we propose a structured Newton-Raphson algorithm for a logistic fixed effects model and an approximate EM algorithm for the logistic mixed effects model. We consider a re-sampling and simulation technique to obtain p-values for the proposed measures. Finally, our method of identifying outlier facilities involves converting the observed p-values to Z-statistics and using the empirical null distribution, which accounts for overdispersion in the data. The finite-sample properties of proposed measures are examined through simulation studies. The methods developed are applied to national dialysis data. It is our great pleasure to present this paper in honor of Ross Prentice, who has been instrumental in the development of modern methods of modeling and analyzing life history and failure time data, and in the inventive applications of these methods to important national data problem.

The ageing population, the need for patient care delivery closer to home and reducing travel cost and isolation and, not at least, optimising medical team activity lead to adapt treatment by hemodialysis. Telehealth is an alternative now enabled by recent regulatory changes. We summarize here the regulatory and organisational conditions in a monitored Medicalized Dialysis Unit (MDU) and report the local experience of Saint-Brieuc Hospital; the feasibility and functionality over time (5 years) of this approach was demonstrated in clinical practice with selected patients; over short-term and for a still-limited number of patients, its clinical results are comparable to those observed in a MDU running on a traditional regimen (weekly visits and on-call 24 hours on-site 24 of the nephrologist); the degree of patient satisfaction, some of them very old people, is high. Stability of communications mainly depending of the operators and audio-video quality needed for a friendly and efficient exchange, could be improved. Relevant analysis of cost is necessary to adjust compensation and to encourage the deployment of teledialysis. The development of this technique is suitable in order to maintain oldering populations close to home, to assure the fairest access to medical care and to serve its purpose, which is the care in all its dimensions., (Copyright © 2013 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Introduction: This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT: kidney dialysis or a kidney transplant) in the UK in 2012 and the incidence rates for RRT in Primary Care Trusts and Health Boards (PCT/HBs) in the UK., Methods: Basic demographic and clinical characteristics are reported on patients starting RRT at all UK renal centres. Presentation time, defined as time between first being seen by a nephrologist and start of RRT, was also studied. Age and gender standardised ratios for incidence rates in PCT/HBs were also calculated., Results: In 2012, RRT was initiated in 6,891 patients across the UK, an incidence rate similar to 2011 at 108 per million population (pmp). There were wide variations between PCT/HBs in standardised incidence ratios. The median age for Whites was 66.1 and for non-Whites 57.8 years. Diabetic renal disease remained the single most common cause of renal failure (26%). By 90 days, 66.9% of patients were on haemodialysis (HD), 19.0% on peritoneal dialysis (PD), 8.3% had had a transplant and 5.9% had died or stopped treatment. There was variability between centres in the use of PD as an initial treatment (3-48%). The mean eGFR at the start of RRT was 8.5 ml/min/1.73 m(2) similar to previous years. Late presentation (<90 days) fell from 23.9% in 2006 to 19.3% in 2012. Fifty-three percent of patients who started on HD had died within five years of starting. This compared to 30% and 4% for those starting on PD or transplant respectively., Conclusions: The incidence of new patients starting renal replacement therapy in the UK has remained unchanged for almost 10 years in contrast to the rising prevalence. The year on year increase in pre-emptive transplantation is encouraging but the variability between centres in the percentages starting on PD should be explored further., (© 2014 S. Karger AG, Basel.)

Background: The demand for kidney transplant exceeds organ supply; therefore, understanding patient-related and contextual factors associated with waiting list activation is key in ensuring that organ allocation is efficient and equitable. We sought to assess whether inequalities in wait-listing probability exist across centers and evaluate correlates of wait-listing in Italy., Methods: We linked the MigliorDialisi dataset (1,238 patients enrolled in 54 Italian hemodialysis centers) to administrative data concerning the activity of each participating center and contextual information abstracted from the Italian Institute of Statistics. We modeled the odds of waiting list activation for patients on dialysis by the subjects' sociodemographic, biomedical and psychosocial factors along with center-related and contextual factors., Results: The crude enlistment rate was 26% (95% CI 9-54) distributed as follows: 21, 34 and 33% in northern, central, and southern Italy, respectively (p < 0.01). Older patients with poorer health conditions and lower expectations toward transplantation outcomes were less likely to be wait-listed in multilevel multivariable logistic regression. In the fully adjusted model there was not a statistically significant variation in wait-listing across northern, central, and southern regions. However, the variance explained by center-related factors accounted for 12% (p < 0.01) of total variability in enlistment likelihood (20% in patients >65 years, p < 0.01)., Conclusions: Our results showed that inter-center variation exists after adjusting for case mix. Additionally, we identified individual modifiable factors associated with wait-listing inequalities., (Copyright © 2013 S. Karger AG, Basel.)

Introduction: This chapter describes the characteristics of adult patients on renal replacement therapy (RRT) in the UK in 2012., Methods: Data were electronically collected from all 71 renal centres within the UK. A series of crosssectional and longitudinal analyses were performed to describe the demographics of prevalent RRT patients in 2012 at centre and national level., Results: There were 54,824 adult patients receiving RRT in the UK on 31st December 2012. The UK adult prevalence of RRT was 861 pmp. This represented an annual increase in absolute prevalent numbers of approximately 3.7%, although there was variation between centres and Primary Care and Health Board areas. The actual number of patients increased across all modalities: 2.3% haemodialysis (HD), 0.3% peritoneal dialysis (PD) and 5.6% for those with a functioning transplant. The number of patients receiving home HD has increased by 19.3% since 2011. Median RRT vintage for patients on HD was 3.4 years, PD 1.7 years and for those patients with a transplant, 10.2 years. The median age of prevalent patients was 58 years (HD 66 years, PD 63 years, transplant 52 years) compared to 55 years in 2005. For all ages the prevalence rate in men exceeded that in women. The most common recorded renal diagnosis was glomerulonephritis (biopsy proven/not biopsy proven) (18.8%). Transplantation was the most common treatment modality (50.4%), Conclusions: The HD and transplant population continued to expand; the decline in the size of the prevalent PD population has plateaued. There were national, regional and dialysis centre level variations in prevalence rates. Prevalent patients were on average three years older than the prevalent RRT cohort 7 years ago. This has continued implications for service planning and ensuring equity of care for RRT patients., (© 2014 S. Karger AG, Basel.)

Objectives: Risk factors of mortality in patients with haemodialysis (HD) have been identified in several studies, but few prognostic models have been developed with assessments of calibration and discrimination abilities. We used the database of the Assessment of Survival and Cardiovascular Events study to develop a prognostic model of mortality over 3-4 years., Methods: Five factors (age, albumin, C-reactive protein, history of cardiovascular disease and diabetes) were selected from experience and forced into the regression equation. In a 67% random try-out sample of patients, no further factors amongst 24 candidates added significance (P < 0.01) to mortality outcome as assessed by Cox regression modelling, and individual probabilities of death were estimated in the try-out and test samples. Calibration was explored by calculating the prognostic index with regression coefficients from the try-out sample to patients in the 33% test sample. Discrimination was assessed by receiver operating characteristic (ROC) areas., Results: The strongest prognostic factor in the try-out sample was age, with small differences between the other four factors. Calibration in the test sample was good when the calculated number of deaths was multiplied by a constant of 1.33. The five-factor model discriminated reasonably well between deceased and surviving patients in both the try-out and test samples with an ROC area of about 0.73., Conclusions: A model consisting of five factors can be used to estimate and stratify the probability of death for individuals The model is most useful for long-term prognosis in an HD population with survival prospects of more than 1 year., (© 2011 The Association for the Publication of the Journal of Internal Medicine.)

A cross-sectional study was made of the prevalence of HCV and associated risk factors in 382 multi-transfused patients and haemodialysis staff in Yadz province in 2006. Of those tested for anti-HCV antibodies, 50.6% of patients with inherited bleeding disorders, 11.8% with thalassaemia and 5.0% undergoing haemodialysis were seropositive. First transfusion before 1996 (when blood donor screening started) was the common risk factor associated with HCV infection. Only 1/52 haemodialysis staff members was HCV infected (an intravenous drug user). Infection control measures were poor in all centres. In patients with inherited bleeding disorders genotype 1 (65.0%) was the predominant followed by genotype 3 (35.0%). The results provide evidence that blood donor screening and use of virus-inactivated factor concentrates have lowered the risk of HCV infection among multi-transfused patients.

Purpose: Hemodialysis patients undergo frequent and long visits to the clinic to receive adequate dialysis treatment, medical guidance, and support. This may affect health-related quality of life (HRQOL). Although HRQOL is a very important management aspect in hemodialysis patients, there is a paucity of information on the differences in HRQOL between centers. We set out to assess the differences in HRQOL of hemodialysis patients between dialysis centers and explore which modifiable center characteristics could explain possible differences., Methods: This cross-sectional study evaluated 570 hemodialysis patients from 24 Dutch dialysis centers. HRQOL was measured with the Kidney Disease Quality Of Life-Short Form (KDQOL-SF)., Results: After adjustment for differences in case-mix, three HRQOL domains differed between dialysis centers: the physical composite score (PCS, P = 0.01), quality of social interaction (P = 0.04), and dialysis staff encouragement (P = 0.001). These center differences had a range of 11-21 points on a scale of 0-100, depending on the domain. Two center characteristics showed a clinical relevant relation with patients' HRQOL: dieticians' fulltime-equivalent and the type of dialysis center., Conclusion: This study showed that clinical relevant differences exist between dialysis centers in multiple HRQOL domains. This is especially remarkable as hemodialysis is a highly standardized therapy.

Introduction: These analyses examine a) survival from the start of renal replacement therapy (RRT), based on the total incident UK RRT population reported to the UK Renal Registry, including the 18% who started on PD and the 7% who received a pre-emptive transplant and b) survival of prevalent patients. Changes in survival between 1997 and 2009 are also reported., Methods: Survival of incident patients (starting RRT during 2009) was calculated both from the start of RRT and from 90 days after starting RRT, both with and without censoring at transplantation. Survival of prevalent dialysis patients was calculated to exclude patients once they were transplanted. Both Kaplan-Meier and Cox adjusted models were used to calculate survival. Causes of death were analysed for both groups. Relative risk of death was calculated compared with the general UK population., Results: The 2009 unadjusted 1 year after 90 day survival for patients starting RRT was 86.6% (87.3% in 2008). In incident patients aged 18-64, the unadjusted 1 year survival had increased from 86.0% in 1997 to 91.3% in 2009. In incident patients aged ≥ 65, unadjusted 1 year survival had improved from 64.1% to 76.2%. There were no survival differences between genders. The relative risk of death compared to the general population decreased from 25 times at age 30-34 to 2.7 times at age 85+. Cause of death data completeness has improved 18% since last year. Cardiac disease is the most common cause of death in prevalent dialysis patients and malignancy most frequent in prevalent transplant patients., Conclusions: Survival of patients starting RRT has improved for all ages since 1997. The frequency of cardiac disease as the cause of death has decreased since 1997., (Copyright © 2012 S. Karger AG, Basel.)

Background: The central paradigm of effective peritoneal dialysis (PD) is an appropriate standard of PD catheter function., Aim: The ultimate aim of the project is to develop an effective national PD access audit which will identify what represents an 'appropriate standard' of PD catheter function., Methods: A 2009 Renal Association working party recommended that the UK Renal Registry should collect centre specific information on various PD access outcome measures including catheter functionality and post-insertion complications., Results: The first PD access audit covering England, Northern Ireland and Wales was conducted during April to June 2012 looking at incident dialysis patients in 2011. Forty three data collection spreadsheets were returned from a total of 63 centres describing 863 PD catheter placements of which 225 had a missing date of insertion. Results will be published on the UK Renal Registry website as soon as they are available., Discussion: There is clearly much to be learned as the project is progressed, including minimising data ambiguities and trying to maximise data completeness (for example it is possible that a patient with a catheter that never worked and never had PD may be overlooked in this audit). However, a comparative PD catheter audit has the potential to provide valuable information on an important patient related outcome measure and lead to an improvement in patient experience., (Copyright © 2012 S. Karger AG, Basel.)

Aims: To describe the demographics of the paediatric RRT population under the age of 16 years in the UK and to analyse changes in demography with time., Methods: Data were collected from all 13 paediatric renal centres within the UK. A series of cross-sectional and longitudinal analyses were performed to describe the demographics of prevalent paediatric RRT patients., Results: A total of 870 children and young people under 18 with ERF were receiving treatment at paediatric nephrology centres in 2010. At the census date, 76.7% had a functioning transplant, 14.3% were receiving peritoneal dialysis (PD) and 9.0% were receiving haemodialysis (HD). In patients aged <16 years the prevalence of ERF was 59.3 pmarp and the incidence 8.1 pmarp. Analysis of trends over the last 15 years shows that both incidence and prevalence are increasing with the most marked increases in children aged 12-16 years and in ethnic minority groups. A third of the patients have one or more reported comorbidities. At transfer to adult services, 84.9% of patients had a functioning renal transplant., Conclusions: The data provided in this report show increasing trends over 15 years in the incidence and prevalence of established renal failure. This is important for the planning of the provision of care for children needing renal replacement therapy. The inclusion this year of an analysis of the patients transferring to adult services may assist in developing care pathways for this vulnerable group., (Copyright © 2012 S. Karger AG, Basel.)

Introduction: The UK Renal Association clinical practice guidelines include clinical performance measures for biochemical variables in dialysis patients. The UK Renal Registry (UKRR) annually audits dialysis centre performance against these measures as part of its role in promoting continuous quality improvement., Methods: Cross sectional performance analyses were undertaken to compare dialysis centre achievement of clinical audit measures for prevalent haemodialysis (HD) and peritoneal dialysis (PD) cohorts in 2010. The biochemical variables studied were phosphate, adjusted calcium, parathyroid hormone, bicarbonate and total cholesterol. In addition longitudinal analyses were performed (2000-2010) to show changes in achievement of clinical performance measures over time., Results: Fifty-six percent of HD and 69% of PD patients achieved a phosphate within the range recommended by the RA clinical practice guidelines. Seventy-five percent of HD and 76% of PD patients had adjusted calcium between 2.2-2.5 mmol/L. Twenty-eight percent of HD and 31% of PD patients had parathyroid hormone between 16- 32 pmol/L. Sixty percent of HD and 80% of PD patients achieved the audit measure for bicarbonate. There was significant inter-centre variation for all variables studied., Conclusions: The UKRR consistently demonstrates significant inter-centre variation in achievement of biochemical clinical audit measures. Understanding the causes of this variation is an important part of improving the care of dialysis patients in the UK., (Copyright © 2012 S. Karger AG, Basel.)

Introduction: Infection remains one of the leading causes of death in patients with end-stage renal failure (ESRF) receiving dialysis. Since April 2007, all centres providing renal replacement therapy in England have been required to provide additional data on patients with Methicillin Resistant Staphylococcus Aureus (MRSA) infection. From January 2011 this has also been required for patients with Methicillin Sensitive Staphylococcus Aureus (MSSA). MRSA data for 2009-2011 and the first 6 months of MSSA data are reported., Methods: Potential bacteraemia were identified by the Health Protection Agency based on clinical details provided and the clinical setting. The records were 'shared' with the parent renal centre who then complete the additional data on the HCAI-DCS website. Centres were also contacted by phone and email as a further validation step., Results: From April 2009-2010 there were 77 confirmed episodes of MRSA bacteraemia at a median rate of 0.25 per 100 prevalent dialysis patients. This number decreased to 61 episodes between April 2010-2011 at a median rate of 0 per 100 prevalent dialysis patients. Overall there has been an 82% reduction in absolute episodes since the first year of mandatory reporting in 2007. The incidence of bacteraemia in patients with a central venous catheter was approximately six fold higher than in those with an AV fistula. From 1st January to 30th June 2011 there were 160 episodes of MSSA bacteraemia with a rate of 1.06 episodes per 100 dialysis patients, again the risk was six fold higher in patients with a CVC., Conclusions: Overall rates of MRSA bacteraemia in dialysis patients continued to fall although there remained variation between renal centres. Initial data from the early days of MSSA reporting suggested high rates of infection and an even greater variation between renal centres. This requires confirmation from future data collection., (Copyright © 2012 S. Karger AG, Basel.)

Background: The British Association for Paediatric Nephrology Registry was established to analyse data related to renal replacement therapy (RRT) for children. The registry receives data from the 13 paediatric nephrology centres in the UK., Aim: To provide centre specific data so that individual centres can reflect on the contribution that their data makes to the national picture and to determine the extent to which their patient parameters meet nationally agreed audit standards for the management of children with established renal failure., Method: Data returns have been a mixture of electronic and paper returns. Data were analysed to calculate summary statistics and where applicable the percentage achieving an audit standard. The standards used were those set out by the Renal Association and the National Institute for Health and Clinical Excellence., Results: Anthropometric data confirmed that children receiving RRT are short compared to healthy peers. Amongst patients with a height z-score of <2SD between 2000 and 2010, 27% were receiving growth hormone if they were on dialysis compared to 10% if they had a functioning transplant. Blood pressure was higher in children receiving RRT than in healthy children with wide inter-centre variation. The percentage of patients achieving the treatment standards for haemoglobin and ferritin has gradually increased over the last decade, more noticeably in dialysis patients. Analysis by age showed that the proportion of children with a haemoglobin below the standard was greatest for the under 5 years age group irrespective of RRT modality. The control of renal bone disease remained challenging., Conclusions: Optimizing growth in children on RRT remains challenging and the control of bone biochemistry in children on dialysis is imperfect. However there is some room for optimism as this year's data shows an improving trend in the control of anaemia and systolic blood pressure., (Copyright © 2012 S. Karger AG, Basel.)

Introduction: Missing data has hampered the comprehensive and inclusive reporting of adjusted outcomes for patients on renal replacement therapy (RRT) captured by the UK Renal Registry (UKRR). Furthermore the information collected by the UKRR does not currently include morbidity after starting RRT, details on hospital admission rates or location of death. Linking datasets offers the opportunity to enhance existing data and describe new measures of centre performance., Methods: 21,633 incident patients, starting RRT between 2002 and 2006, were linked to all hospital care recorded by the Hospital Episode Statistics (HES) database and Office of National Statistics (ONS) mortality data using a secure anonymised service. Comorbidity prior to admission was determined from ICD10 coded HES admission diagnoses before the start of RRT, along with missing data on ethnicity and socioeconomic status. Location of death was determined by comparing the ONS and UKRR date of death to concurrent hospitalisations from HES., Results: 290,443 admissions, 2.2 million haemodialysis attendances, 1.5 million outpatient attendances and 11,546 ONS deaths were returned for this cohort. Coding depth improved over time and varied between centres. Following linkage 21,271 patients were suitable for analysis, with improvements in ethnicity completeness (75.5% to 98.9%) and socioeconomic status (72.0% to 98.6%). Comorbidity improved substantially from 53.7% to 98.1% with 93% concordance in those with UKRR data. Mean comorbid scores between centres was similar (0.73-1.14) but variation in the proportion of admissions under nephrology in the first 12 months and the location of death between centres was noted, suggesting differing policies, practices and coding methods., Conclusions: Linking routine healthcare datasets with a national registry has dramatically reduced missing data and enables reporting of additional comprehensively adjusted measures of performance that allow more robust comparisons between centres. Hospitalisation frequency and associated mortality can be described in much greater detail. Linking routine datasets to national audits and registries represents an achievable, cost-effective and illuminating new way to evaluate services such as renal replacement therapy in the English NHS., (Copyright © 2012 S. Karger AG, Basel.)