Program Helps With Transition to Renal Replacement Therapy

Pam Harrison

November 18, 2016

CHICAGO — When patients with late-stage kidney disease participate in a program to help them transition to dialysis, they are better prepared and more knowledgeable about their treatment options, new research shows.

Care for patients with late-stage chronic kidney disease "is truly suboptimal in the United States, which leads to a number of gaps that patients experience as they transition" from the late stage to the end stage of disease, said Steven Fishbane, MD, from the Hofstra Northwell School of Medicine in Great Neck, New York.

"We found the Healthy Transitions intervention to be highly efficacious for improving end-stage kidney disease preparation," he told delegates here at Kidney Week 2016.

The program, developed about 5 years ago at the Hofstra Northwell School of Medicine, focuses on the nursing management of patients with late-stage chronic kidney disease.

"Nurses work in close collaboration with nephrologists," Dr Fishbane explained. They facilitate patient care and help the patient navigate "the very complex processes involved in the transition to dialysis."

Nurses are well placed to "properly prepare and educate patients and their caregivers about the options available to them," he added. And Hofstra has a proprietary informatics system that allows nurses to work with different protocols and focus on outcomes of the sickest patients.

To date, approximately 680 patients have completed the program, he reported.

The researchers presented results from a randomized controlled trial that compared patients who had gone through the program with patients who received standard nephrology care.

Enrolment in the program took place in 2013 and 2014. Participants with late-stage chronic kidney disease were older than 18 years and had an estimated glomerular filtration rate (eGFR) of 30 mL/min per 1.73 m² or less. All came from one of three nephrology offices: an academic nephrology clinic, a country hospital with an academic clinic, and a private nephrology practice.

Of the 130 patients, 65 were randomized to the 18-month Healthy Transitions program and the other 65, who served as the control group, were randomized to standard nephrology care.

The study cohort was a fairly representative sample of patients with late-stage chronic kidney disease in the United States. Mean eGFR at baseline was 18 to 19 mL/min per 1.73 m².

The intent-to-treat analysis showed that patients in the program had a better understanding of the options for renal replacement therapy than those receiving standard care.

Table. Initial Management Choices of the Study Participants

Initial Management Intervention Group, % Control Group, % P Value
Peritoneal dialysis 23 3 .05
Hemodialysis in an outpatient center, not a hospital 58 23 .029

 

More patients in the intervention group than in the control group opted for pre-emptive transplantation over the initiation of dialysis, although the difference was not significant (13.0% vs 6.5%).

Only 2.6% of patients in the US Renal Data System undergo pre-emptive transplantation as their initial treatment for end-stage kidney disease, Dr Fishbane reported. And almost two-thirds of patients in the United States requiring dialysis start dialysis in the hospital rather than in a hemodialysis unit.

"We had a few quality measures of preparedness as well. These included outcomes where patients started dialysis with a home modality or had a pre-emptive kidney transplantation or started hemodialysis with a working fistula or graft," he explained.

More patients in the intervention group than in the control group met this combination of quality measures of preparedness (70% vs 32%).

Another quality measure of education — the move toward home modalities or pre-emptive transplantation — was also significantly higher in the intervention group than in the control group (37% vs 10%).

The initiation of hemodialysis with a catheter in place on day 1 was less common in the intervention group than in the control group (37% vs 68%). Overall, 80% of patients in the United States initiate hemodialysis with a catheter in place on day 1.

In addition, more patients in the intervention group than in the control group started with an arteriovenous fistula or a mature graft on day 1 of dialysis, although the difference was not significant (52% vs 28%).

At the time of the intervention, Hofstra did not have a home dialysis program or a conservative-care management program in place. However, both have now become part of the overall end-stage kidney disease care program, Dr Fishbane reported

The program is easily incorporated into general nephrology practices, although reimbursement remains a challenge, he noted.

The primary goal of the intervention is to reduce hospitalizations in patients with end-stage kidney disease. The research team is currently analyzing the data to assess this and to determine whether the intervention is more cost-effective than standard nephrology care.

 
These were whopping effects in terms of better preparing people for end-stage kidney disease.
 

The results from the Healthy Transitions program are "pretty profound," said session cochair Kalani Raphael, MD, from University of Utah Health Care in Salt Lake City.

"These were whopping effects in terms of better preparing people for end-stage kidney disease," he told Medscape Medical News. "And we absolutely need to better prepare these people for the transition to dialysis."

Dr Fishbane and Dr Raphael have disclosed no relevant financial relationships.

Kidney Week 2016: American Society of Nephrology Annual Meeting: Abstract TH-OR039. Presented November 17, 2016.

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