Background: Chronic Kidney Disease is a global health problem. In the United Kingdom, there is impetus for self-management of long term conditions. In 2002, the National Institute for Health and Clinical Excellence’ technology appraisal guideline on haemodialysis suggested that 10%-15% of the centre’s dialysis population should undertake home haemodialysis. The clinical community is yet to rise to this challenge. In this study, we seek to explore patient-related clinical and psychosocial predictors and provider beliefs and attitudes which determine the choice of self-care dialysis, particularly, home haemodialysis. Design and methods: The design is a combined cross-sectional and longitudinal study employing an integrated mixed methodology (convergent, parallel design). Study participants include patients and multidisciplinary staff. The three patient cohorts (n = 535) include pre-dialysis (222), hospital (213) and self-care haemodialysis patients (100) from geographically distinct NHS sites, and with variable prevalence of home haemodialysis (low <3%; medium 5-8%; high >8%). The pre-dialysis patients were followed up for a period of 12 months from study entry. Quantitative data ascertained include biomarkers, clinical, psychosocial quantitative and neuropsychometric-cognitive tests in the study cohorts. Organizational attitudes and dialysis unit practices were gathered from a survey of the participating units. Semi-structured interviews were carried out for patients and care-providers. The datasets were analysed independently and the findings mixed at the stage of interpretation. Statistical tests appropriate to the specific questions were considered for the quantitative data and qualitative data was analysed using thematic analysis. Results: Home haemodialysis has a high composite (training+home) technique survival rate of 90.2%, 87.4% & 81.5% at 1, 2 and 5-years respectively in a death and transplantation censored analysis. The key predictors of self-care dialysis, especially home haemodialysis, are self-perceived higher cognitive ability (metaconcentration), lower comorbidity score, home ownership, and white ethnicity background. There are 20% lower odds of choosing self-care dialysis over fully-assisted dialysis for every unit reduction in metaconcentration score and this is significantly associated with trails making test B, an objective test of executive brain function. Perceived inability to self-cannulate was a significant predictor of the choice of peritoneal dialysis over home haemodialysis amongst CKD-5, predialysis patients. However, approximately 1 in 3 patients from the predialysis and hospital haemodialysis groups feel able to consider self-cannulation. The centre to which the patient belonged had an impact on the choice of dialysis modality, with greater proportion opting for home haemodialysis in a centre with greater home haemodialysis prevalence. Amongst predialysis patients who made a modality choice, the experience of their interaction with healthcare teams and dialysis counselling, self-efficacy, personal fulfilment through work and social engagements, and their views of the modality’s impact on their significant others, influenced the choice of home or hospital-based haemodialysis. 45% of all respondents in a survey of healthcare practitioners felt that staff knowledge and bias influenced the offer of home haemodialysis therapy. At a policy level, the tariff for home haemodialysis was not a clear incentive for its adoption due to uncertainty about operational costs. Conclusions: There exists a perception of lack of uniformity in practice pertaining to offer of home haemodialysis across the study centres. The impact of financial incentives designed at a policy level is influenced by the understanding of cost and benefits at the local operational level. Most barriers are surmountable and patients should be able to consider self-care therapies option in all but the most limiting physical and cognitive states. There is a need locally, for units to investigate barriers to home haemodialysis therapy using a conceptual framework in order to facilitate change.

Darbo tikslas: įvertinti hemodializuojamų pacientų slaugos ypatumus. Metodika. Tyrimo metu Kauno medicinos universiteto klinikų detoksikacijos skyriuje atlikta anketinė tiriamųjų apklausa. Naudotos dvi anoniminės anketos. Viena anketa buvo skirta hemodialize gydomiems pacientams, kita - slaugytojoms. Anketoje pateikti klausimai skirti įvertinti tiriamųjų sociodemografinius duomenis, nuomonę apie pacientų žinias apie ligą, miegą, prisitaikymą prie pasikeitusio gyvenimo režimo, sveikatos problemų sprendimo būdus, bendravimą su slaugos personalu, jo teikiamą informaciją. Pacientams skirtoje anketoje klausta nuomonės apie jų sveikatą ir jos reikšmę kasdieninei veiklai („Health Survey for Dialysis Patients (SF36)). Apskaičiuojant kiekybinių dydžių vidurkius, po jų nurodytos standartinės paklaidos. Statistinė duomenų analizė atlikta kompiuteriu, naudojant duomenų analizės SPSS (Statistical Package for Social Science) programos paketą. Duomenų skirtumai laikyti reikšmingais, jei reikšmingumo lygmuo p<0,05. Rezultatai. Tyrime dalyvavo 54 hemodializuojami pacientai (34 vyrai ir 20 moterų) nuo 21 m. iki 81 m. amžiaus (vidurkis 58,37±2,072 m.) bei 30 slaugytojų moterų nuo 25 iki 50 metų (vidutinis amžius 37,5±1,45 m.). 40,7 proc. pacientų atvykimas į dializės centrą nesukelia jokių problemų, 40,7 proc. kyla sveikatos problemų, o 18,6 proc. patiria finansinius sunkumus. Kuo mažesnis atstumas nuo pacientų gyvenamosios vietos iki dializės centro, tuo mažiau problemų kyla pacientams (p=0,00... [toliau žr. visą tekstą] / Goal of the work: to assess the nursing peculiarities of hemodialysis patients. Methods. The survey of respondents was performed in performing the research at Kaunas University Hospital. Two anonymous questionnaires were applied. One questionnaire was prepared for hemodialysis patients and another for nurses. The questions in the questionnaire were targeted for evaluation of social demographic data of the researched persons, for the analysis of patient knowledge on their illness, sleep, adaptation to the changed mode of life, methods of solving the health problems, communication with the nursing staff and information provided by it. The questionnaire for patients contained questions on their opinion on their health and its meaning to daily activities („Health Survey for Dialysis Patients (SF36)). While calculating the mean values of the quantitative values, the standard deviations are specified next to them. The statistic data analysis was performed by computer, by using the Statistical Package for Social Science software package. The date the difference was disregarded if the meaning level was p<0.05. Results. 54 hemodialysis patients took part in the research (34 men and 20 women) from 21to 81 year age (average 58.37±2.072 years) and 30 nurses - women from 25 to 50 year age (average 37.5±1.45 years). For 40.7 percent of patients their arrival to the dialysis centre causes no problems, 40.7 percent have health problems, and 18.6 percent have financial difficulties. The less... [to full text]

<p>The aim of this study was to investigate which situations haemodialysis patients consider as the hardest for avoiding fluid intake. The data collection was performed with a questionnaire which was distributed to haemodialysis patients who fulfilled the inclusioncriteria. Of 158 haemodialysis patients 103 haemodialysis patients chose to participate in the study. The participants were chosen from different dialysis centres (n=12) in north and south of sweden, excluding the middle of Sweden. The questionnaire that was given out consisted of 32 situations, the response format included nine alternatives, that included different kind of difficultes. The nine alternatives were; very easy, easy, neither easy or hard, hard, very hard, impossible, do not know, do not concerns me. The 32 situations were devided into four categories, physiological, affective, social and environmental factors. The main result indicated that it was hardest to avoid fluid in the physiological situations. For exampel when the patients felt a dryness in the mouth, when they felt thirsty or when they hade eaten salty food.</p> / <p>Syftet med studien var att undersöka vid vilka tillfällen hemodialyspatienter ansåg att det är svårast att undvika vätskeintag. Datainsamlingen skedde med en enkät som delades ut till dialyspatienter som uppfyllde författarnas förbestämda inklusionskriterierna. Av 158 patienter så valde 103 dialys patienter att delta i studien. Deltagarna valdes ifrån dialysenheter (n=12) som låg söder om Örebro samt norr om Sundsvall dvs mellan Sverige togs ej med. Enkäten som delades ut bestod av 32 olika situationer och till dem hörde nio olika svarsalternativ som innefattade olika svårighets grader. De nio olika svarsalternativen var; inga problem, mycket lätt, lätt, varken lätt eller svårt, svårt, mycket svårt, omöjligt, vet ej samt gäller inte mig. I databearbetningen delades de 32 olika situationer in i fyra olika grupper, fysiologiska, affektiva, sociala och miljöfaktorer. Huvudresultatet visade att det i de fysiologiska situationerna var svårast att följa vätskerestriktionerna. Exempelvis när patienterna kände sig torra i munnen, kände sig törstiga samt när de åt salt mat.</p>

Cardiovascular disease is a major cause of mortality and morbidity in patients on chronic haemodialysis (HD). One main contributing factor is renal dyslipidaemia, characterized by an impaired catabolism of triglyceride (TG)-rich lipoproteins with accumulation of atherogenic remnant particles. The enzyme lipoprotein lipase (LPL) is a key molecule in the lipolysis of TG-rich lipoproteins into free fatty acids. The activity of LPL is reduced in HD-patients. This study was performed to elucidate various conditions and factors that may have an impact on LPL-related lipid metabolism. I. The functional pool of LPL is located at the vascular surface. The enzyme is released by heparin and low molecular weight heparins (LMWH) into the circulating blood and extracted and degraded by the liver. Heparin and LMWH are used for anticoagulation during HD to avoid clotting in the extracorporeal devices. This raises a concern that the LPL system may become exhausted by repeated administration of LMWH in patients on HD. In a randomized cross over designed study twenty patients on chronic HD were switched from a primed infusion of heparin to a single bolus of LMWH (tinzaparin).  The LPL activity in blood was higher on HD with LMWH at 40 minutes but lower at 180 minutes compared to HD with heparin. These values did not change during the 6-month study period. With heparin a significant TG reduction was found at 40 minutes and a significantly higher TG value at 180 and 210 minutes than at start. TG was higher during the HD-session with tinzaparin than with heparin. Our data demonstrate that repeated HD with heparin or with LMWH does not exhaust the LPL-system in the long term but does disturb the LPL system and TG metabolism during every HD session. II. In this study HD patients were compared with patients on peritoneal dialysis (PD) in a case control fashion. PD patients showed the same reaction of the LPL system to LMWH as HD patients. This confirmed that both HD and PD patients had the same, reduced, heparin-releasable LPL pool. The main difference was that in PD patients the TG continued to be cleared effectively even at 180 minutes after the bolus of LMWH injection. This may be due to a slower removal of the released LPL by the liver in PD patients.  III. In recent years, citrate (Citrasate) in the dialysate has been used in Sweden as a local anticoagulant for chronic HD. We performed a randomized cross over study that included 23 patients (16 men and 7 women) to investigate if citrate in the dialysate is safe and efficient enough as anticoagulant. The study showed that citrate anticoagulation eliminated the need of heparin or LMWH as anticoagulation for HD in half of the patients. However, individual optimization of doses of anticoagulants used together with citrate have to be made. IV. Recently angiopoietin-like proteins, ANGPTL3 and 4 have emerged as important modulators of lipid metabolism as potent inhibitors of LPL. Twenty-three patients on chronic HD and 23 healthy persons were included as case and controls to investigate the levels of these proteins in plasma of HD-patients and to evaluate if HD may alter these levels. The data showed that plasma levels of ANGPTL3 and 4 were increased in patients with kidney disease compared to controls. This may lead to inactivation of LPL. High flux-HD, but not low flux-HD, reduced the levels of ANGPTL4, while the levels of ANGPTL3 were not significantly influenced.  On HD with local citrate as anticoagulant, no LPL activity was released into plasma during dialysis in contrast to the massive release of LPL with heparin (LMWH). Citrate HD was not associated with a significant drop in plasma TG at 40 minutes, while both HD with citrate and heparin resulted in significantly increased TG levels at 180 minutes compared to the start values. Conclusions:  Citrate as a local anticoagulant during haemodialysis eliminates the need of heparin or LMWH in about half of the HD patients. Citrate does not induce release of LPL from its endothelial binding sites. We have shown that although HD with heparin causes release of the endothelial pool of LPL during each dialysis session, the basal pool is similarly low in PD patients that do not receive heparin. This indicates that the LPL pool is lowered as a consequence of the uraemia, per se. One explanation could be the increased levels of ANGPTL3 and 4. HD with high flux filters can temporarily lower the levels of ANGPTL4. Further studies are, however, needed to understand why LPL activity is low in patients with kidney disease.

The aim of this study was to investigate which situations haemodialysis patients consider as the hardest for avoiding fluid intake. The data collection was performed with a questionnaire which was distributed to haemodialysis patients who fulfilled the inclusioncriteria. Of 158 haemodialysis patients 103 haemodialysis patients chose to participate in the study. The participants were chosen from different dialysis centres (n=12) in north and south of sweden, excluding the middle of Sweden. The questionnaire that was given out consisted of 32 situations, the response format included nine alternatives, that included different kind of difficultes. The nine alternatives were; very easy, easy, neither easy or hard, hard, very hard, impossible, do not know, do not concerns me. The 32 situations were devided into four categories, physiological, affective, social and environmental factors. The main result indicated that it was hardest to avoid fluid in the physiological situations. For exampel when the patients felt a dryness in the mouth, when they felt thirsty or when they hade eaten salty food. / Syftet med studien var att undersöka vid vilka tillfällen hemodialyspatienter ansåg att det är svårast att undvika vätskeintag. Datainsamlingen skedde med en enkät som delades ut till dialyspatienter som uppfyllde författarnas förbestämda inklusionskriterierna. Av 158 patienter så valde 103 dialys patienter att delta i studien. Deltagarna valdes ifrån dialysenheter (n=12) som låg söder om Örebro samt norr om Sundsvall dvs mellan Sverige togs ej med. Enkäten som delades ut bestod av 32 olika situationer och till dem hörde nio olika svarsalternativ som innefattade olika svårighets grader. De nio olika svarsalternativen var; inga problem, mycket lätt, lätt, varken lätt eller svårt, svårt, mycket svårt, omöjligt, vet ej samt gäller inte mig. I databearbetningen delades de 32 olika situationer in i fyra olika grupper, fysiologiska, affektiva, sociala och miljöfaktorer. Huvudresultatet visade att det i de fysiologiska situationerna var svårast att följa vätskerestriktionerna. Exempelvis när patienterna kände sig torra i munnen, kände sig törstiga samt när de åt salt mat.

Despite chronic dialysis treatment, patients with end stage renal disease undergoing maintenance haemodialysis (HD) remain at a substantially increased risk of morbidity. Previous reports using Doppler ultrasound (DU) during HD have revealed microembolic signals (ME) in the venous circulation. In vitro studies confirm the emergence of microbubbles of air that may pass the security system of the HD circuit without triggering the alarm. The aim of this thesis was to elucidate the presence of ME during HD and examine methods that might reduce exposure to ME in vivo. The first study utilized DU to verify the presence of ME in 40 patients during standard HD. Investigation within 30 minutes after the start of HD and just before the end of session revealed the presence of ME in the venous blood line during both phases. The air trap did not alert for the presence of ME. This indicated that ME may pass into the patient during the entire HD run. Study 2 analyzed the presence of ME prior to start and during HD when measured at the AV-access and also carotid artery. A total of 54 patients were examined using DU as the investigative technique. ME increased significantly after start of HD in the AV-access, but also at the carotid artery site. These data indicated that ME can enter the body and even pass the lung barrier. The question arose if microbubbles of air are resorbed or may cause ischemic lesions in organs such as the brain. Study 3 examined whether the amount of ME detected in the AV-access would change by using either a high or a low blood level in the venous air trap/chamber. This was a prospective, randomized and double-blind study of 20 HD patients who were their own controls. After 30 min of standard HD, measurement of ME with DU was performed for two minutes. The chamber setting was changed and after another 30 minutes a new recording was carried out for two minutes. Data showed that setting a high blood level significantly reduced the extent of ME that entered the patient. The results also indicated that ME consisted mainly of microbubbles. In study 4, twenty patients were randomized in a cross-over setting of HD. Three options were used: a wet-stored dialyzer with high blood level (WH) and a dry-stored dialyzer using either a high (DH) or a low (DL) blood level in the venous chamber. The exposure of ME, detected by DU, was least when using mode WF, more with mode DH, and most with mode DL. There was a correlation between higher blood flow and more extensive exposure to ME. Study 5 was an autopsy study of a chronic HD patient with the aim of searching for microbubbles deposited in organs. Microbubbles of gas were verified in the vessels of the lungs, brain and heart. By using a fluorescent stain of anti-fibrinogen it was verified that the microbubbles were covered by clots that had to be preformed before death occurred. This indicated that air microbubbles are not completely absorbed and could result in embolic deposition in the organs of HD patients. In conclusion, these in vivo studies showed that ME pass the air trap without inducing an alarm and enter the venous blood line of the patient. The data confirmed the presence of ME in the AV-access and also in the carotid artery. Autopsy data of a deceased HD patient demonstrated the presence of microbubbles in the capillaries of the lungs, but also in the systemic circulation such as in the brain and the heart. A high blood level in the venous chamber and wet-stored dialyzer can reduce, but not eliminate the exposure to microbubbles for patients undergoing HD.

Bakgrund: Tidigare forskning visade att anhöriga till personer som undergår hemodialysbehandling går igenom en svår tid. Syfte: Syftet var att beskriva vuxna patienters upplevelser i samband med hemodialysbehndling Metod: En systematisk litteraturstudie genomfördes på tio kvalitativa studier. Dessa analyserades enligt Evans (2002) beskrivande modell. Resultat: Analysen av materialet resulterade i att fem teman med tolv tillhörande subteman, där patienternas upplevelser i samband med hemodilalysbehandlingen framkom. Slutsats: Resultatet beskriver patienternas upplevelser och problem på olika sätt. Dessa olika upplevelser och problem bör tas i beaktning av vårdpersonal, i samband med hemodialysbehandling, för att skapa en god och säker vård, där man ser till den hela människan. Nyckelord: hemodialybehandling, vuxna, upplevelse. / Background: Previous research shows that families of people undergoing hemodialysis are going through a difficult time. Aim: The aim was to describe adult patients' experiences in connection with hemodialysis treatment. Method: A systematic literature review was performed on ten qualitative studies. These were analyzed according to Evans (2002) descriptive model. Result: The analysis of data resulted in five themes, with twelve related subthemes, where patients' experiences in connection with hemodilalysis treatment emerged. Conclusion: The results describe patients' experiences and problems in different ways. These different experiences and concerns should be taken into consideration by health professionals, in conjunction with haemodialysis treatment, in order to create a good and safe care, where we look at the whole person. Keywords: haemodialysis treatment, adult, experience.

Vascular access (VA) is one of the most important determinants of outcomes in haemodialysis (HD). Poor VA outcomes have a significant adverse impact on patient experience, morbidity and mortality and also result in significant burden on the health economy. An arteriovenous fistula (AVF) is accepted as the best HD vascular access. However AVF prevalence is variable and AVFs are associated with a high early failure rate. A small but significant number of AVFs experience late failure further down the line. The purpose of this project, broadly, was to understand VA outcomes, focusing specifically on AVFs. This project involved a series of clinical studies that were specifically designed by the student researcher to investigate various time points in the life cycle of AVFs – from creation and maturation - to its use and subsequent failure. The MANVAS, OPEN and Coil embolisation studies focus on the early phase of AVF development and maturation, whilst, the VA in Home HD study investigates the impact of intensive self-use in a non-healthcare setting. It is followed by the prospective thrombosed vascular access study focusing on the late phase of VA failure. The MANVAS study, a prospective cohort study, was set up with an aim to follow up patients undergoing AVF formation with a view to defining the natural history and maturation process of AVFs, and determine factors which affect outcomes – demographic, clinical, and biological. The OPEN study was designed to investigate poor maturation due to anastomotic failure by the intervention of the OptiflowTM device. The results suggest high maturation rates that were significantly better than those reported in the literature. The coil embolisation study demonstrated that the intervention of coil embolisation is a safe and effective treatment option for failing AVFs with accessory draining veins. The Vascular Access in Home Haemodialysis (HHD) study demonstrated that VA outcomes are significantly better in HHD patients and unadjusted patient survival in the HHD cohort was associated with incident VA. The thrombosed access study is a prospective longitudinal study designed to assess the effectiveness of endovascular access salvage and investigation of factors that impact longer-term access survival. One of the major aims of the study was to analyse outcomes related to prompt restoration of flow for patients presenting with acute failure of fistulae and grafts. The study showed that timely endovascular salvage is highly effective in restoring immediate patency but long-term outcomes remain poor. It also confirms poor outcomes of grafts as compared to AVFs and demonstrates that progression to thrombosis in AVFs portends poorer prognosis. The endovascular technique of balloon maceration, compared to outcomes reported in the literature, appears to be equally safe and effective with no increased risk of clinically significant pulmonary embolism. The clinical studies in this thesis provide a unique insight into the different aspects of the lifecycle of an AVF, and pave the way for an improvement in our fundamental understanding of the natural history and biology of AVFs.

Die Hämodialyse ist das am weitesten verbreitete Verfahren zur Nierenersatztherapie in Deutschland. In Verbindung mit der Nierentransplantation gelingt es damit heute, das Leben junger betroffener Patienten bei guter Lebensqualität um Jahrzehnte zu verlängern. Die überwiegende Mehrzahl der jährlich neu hinzukommenden Patienten ist jedoch über 65 Jahre alt, weist eine hohe Komorbidität auf und toleriert Standard-Hämodialysebehandlungen weit weniger gut. Daraus resultieren höhere Anforderungen an eine Individualisierung der Dialysetherapie. Neue technische Verfahren bieten dafür vielversprechende Ansätze, die hier näher vorgestellt werden sollen. Dies betrifft zum einen die exakte Messung der Flüssigkeitskompartimente des Körpers mittels Bioimpedanz-Spektroskopie. Andererseits kann durch die Implementierung geschlossener Regelkreise zwischen Patient und Maschine die individuelle Behandlungstoleranz signifikant erhöht werden. / Haemodialysis is the most significant method in renal replacement therapy in Germany. In alliance with kidney transplantation, it offers survival over decades with a reasonable good quality of life – especially to young patients. Today, however, the vast majority of incident patients are older than 65 years and display a considerable degree of co-morbidity, which in turn reduces their tolerance of standard treatment. New tools for an individualisation of haemodialysis therapy are therefore clearly needed. The most promising technical developments in this context are summarised here, including precise measurement of the fluid compartments in patients by way of bioimpedance spectroscopy, as well as closed feedback loops for a tighter integration between patient and dialysis machine.

This study looked into paients’ experiences of end stage renal disease (ESRD) and renal replacement therapy (RRT). A qualitative me thodology was employed involving fifteen patients between the ages of 20 – 60 years that were interviewed on their experiences using the semi structured approach to interviewing. The knowledge gained was analysed thematically. The study was explored within two theoretical frameworks, namely the biopsychosocial and the ecological models. Results of the study revealed that ESRD and RRT posed many psychosocial challenges at a micro and macro level, as patients attempted to reconcil e these experiences with their lifestyles and lives. Challenges were expressed in the areas of functional capacity, work and sexuality. Family life was seriously affected when patients had to make themselves available for life long tr eatment that depended on machines. Recommendations included mobilisatio n of positive support networks, religion/spirituality, and pr ofessional support playing an interrelational role in enabling patients to cope through the long term process so that they may emerge from it with a modicum of quality in their life. Thus a team approach was key to optimal living for the patient. From an ecological perspective, macrosystemic change was also considered important for government to introduce policies that ensure economically productive living for persons with kidney dysfunction. / Thesis (M.A.)-University of KwaZulu-Natal, Durban, 2008.