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Christopher T Chan - One of the best experts on this subject based on the ideXlab platform.

  • Home Hemodialysis and peritoneal dialysis patient and technique survival in canada
    Kidney International Reports, 2020
    Co-Authors: Annieclaire Nadeaufredette, Karthik K Tennankore, Jeffrey Perl, Joanne M Bargman, David W Johnson, Christopher T Chan
    Abstract:

    Abstract Introduction As interest for Home dialysis is growing, knowledge of comparative clinical outcomes between peritoneal dialysis (PD) and Home Hemodialysis (HHD) would help better inform shared decision-making with patients and caregivers during modality discussion. This study aimed to assess differences in risk of mortality and technique failure in an incident Home dialysis cohort, and, specifically, assess change in this association through eras. Methods All adults patients initiating PD or HHD, in Canada (excluding Quebec), within 365 days after kidney replacement therapy (KRT) initiation between 2000 and 2013 were included (administrative censoring December 31, 2014). Mortality and treatment failure (transfer to another modality for >90 days or death) were assessed in a multivariable Cox proportional hazard model, with pre-specified stratification based on the year of KRT initiation. Results The study included 959 HHD and 15,469 PD patients. Compared with incident PD, incident HHD was associated with a lower risk of mortality (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.53-0.78) and treatment failure (aHR 0.52, 95% CI 0.45-0.60). These lower risks of mortality with HHD were more pronounced for older cohorts (2000-2005 aHR 0.47, 95% CI 0.31-0.70; 2006-2010 aHR 0.70, 95% CI 0.54-0.89) and not significantly different in the most recent era (2011-2013 aHR 0.86, 95% CI 0.51-1.47). Conclusion In incident Canadian KRT patients, HHD was associated with appreciably lower risks of mortality and treatment failure compared to PD, although this association appeared to be attenuated in the most contemporary era.

  • changes in pulmonary restrictive parameters by intensive Home Hemodialysis a case report
    BMC Nephrology, 2020
    Co-Authors: Christopher T Chan, Rose Faratro, Thatsaphan Srithongkul, Owen D Lyons
    Abstract:

    Patients with End-Stage Renal Disease (ESRD) are at an increased risk for restrictive lung disease due to accumulation of uremic toxins and volume overload. Hemodialysis is the preferred treatment for improving lung function in dialysis patients. However, the effects of fluid removal and solute clearance by Hemodialysis on lung function remain unclear. We report a case of restrictive lung disorder in a Hemodialysis patient, who showed improvement in both clinical and spirometric lung function after initiation of intensive Home Hemodialysis (32 h per week). Intensive Hemodialysis augments fluid removal and solute clearance, which in turn may improve restrictive lung function.

  • ventricular ejection fraction over time in patients on intensive Home Hemodialysis a retrospective cohort study
    Hemodialysis International, 2020
    Co-Authors: Michael Girsberger, Emilie Trinh, Christopher T Chan
    Abstract:

    Introduction Intensive Hemodialysis has been demonstrated to have several beneficial cardiovascular effects. There is a paucity of studies examining the effect of intensive Home Hemodialysis (IHHD) on left ventricular ejection fraction (LVEF). Methods We conducted a retrospective cohort study at the Toronto General Hospital including all IHHD patients between 1999 and 2017 with baseline and follow-up echocardiograms for at least a year. Patients were categorized according to LVEF at follow-up: patients with normal and patients with abnormal LVEF and/or a decline in LVEF. Normal LVEF was defined as ≥55% and a decline as ≥5% at follow-up compared to baseline Cox regression analyses were performed to ascertain the association between reduced LVEF and reaching the composite endpoint of death, cardiovascular hospitalization, and technique failure, respectively. Multivariate logistic analysis was used to investigate possible risk factors for changes in LVEF. Findings A total of 154 patients were included in the study. At baseline, 18.8% (29/154) of patients had reduced LVEF. After a mean follow-up of 3.9 years, overall mean LVEF did not change (59.3% [at follow-up] vs. 59.9% [baseline], P = 0.45). Seventeen out of the 130 patients with normal LVEF (13.1%) and nine out of the 24 with abnormal LVEF (37.9%) reached the composite endpoint of death, cardiovascular hospitalization, or technique failure. Reduced LVEF at baseline odds ratio ((OR) 13.26 [95% confidence interval (CI) 4.62-38.05]) as well as coronary heart disease (OR 7.82 [95% CI 1.92-31.82]) were associated with reduced ejection fraction at follow-up. When adjusted for age and diabetes, patients with abnormal LVEF were more likely to reach the composite endpoint hazard ratio ((HR) 3.85, 95% CI 1.70-8.71). We did not identify a risk factor associated with progression or worsening of LVEF. Discussion Preserved LVEF occurs in most patients on IHHD and is associated with better clinical outcomes. Further studies are needed to identify the mechanism affecting left ventricular function in patients undergoing intensive Hemodialysis.

  • a comparison of technique survival in canadian peritoneal dialysis and Home Hemodialysis patients
    Nephrology Dialysis Transplantation, 2019
    Co-Authors: Emilie Trinh, Jeffrey Perl, Annieclaire Nadeaufredette, James A Hanley, Christopher T Chan
    Abstract:

    Background High discontinuation rates remain a challenge for Home Hemodialysis (HHD) and peritoneal dialysis (PD). We compared technique failure risks among Canadian patients receiving HHD and PD. Methods Using the Canadian Organ Replacement Register, we studied adult patients who initiated HHD or PD within 1 year of beginning dialysis between 2000 and 2012, with follow-up until 31 December 2013. Technique failure was defined as a transfer to any alternative modality for a period of ≥60 days. Technique survival between HHD and PD was compared using a Fine and Gray competing risk model. We also examined the time dependence of technique survival, the association of patient characteristics with technique failure and causes of technique failure. Results Between 2000 and 2012, 15 314 patients were treated with a Home dialysis modality within 1 year of dialysis initiation: 14 461 on PD and 853 on HHD. Crude technique failure rates were highest during the first year of therapy for both Home modalities. During the entire period of follow-up, technique failure was lower with HHD compared with PD (adjusted hazard ratio = 0.79; 95% confidence interval 0.69-0.90). However, the relative technique failure risk was not proportional over time and the beneficial association with HHD was only apparent after the first year of dialysis. Comparisons also varied among subgroups and the superior technique survival associated with HHD relative to PD was less pronounced in more recent years and among older patients. Predictors of technique failure also differed between modalities. While obesity, smoking and small facility size were associated with higher technique failure in both PD and HHD, the association with age and gender differed. Furthermore, the majority of discontinuation occurred for medical reasons in PD (38%), while the majority of HHD patients experienced technique failure due to social reasons or inadequate resources (50%). Conclusions In this Canadian study of Home dialysis patients, HHD was associated with better technique survival compared with PD. However, patterns of technique failure differed significantly among these modalities. Strategies to improve patient retention across all Home dialysis modalities are needed.

  • buttonhole versus stepladder cannulation for Home Hemodialysis a multicenter randomized pilot trial
    Clinical Journal of The American Society of Nephrology, 2019
    Co-Authors: Shihhan S Huang, Jennifer M Macrae, Dana Ross, Rameez Imtiaz, Brittany Hollingsworth, Gihad Nesrallah, Michael Copland, Philip A Mcfarlane, Christopher T Chan, Deborah Zimmerman
    Abstract:

    Background and objectives Canadian Home Hemodialysis guidelines highlight the potential differences in complications associated with arteriovenous fistula (AVF) cannulation technique as a research priority. Our primary objective was to determine the feasibility of randomizing patients with ESKD training for Home Hemodialysis to buttonhole versus stepladder cannulation of the AVF. Secondary objectives included training time, pain with needling, complications, and cost by cannulation technique. Design, setting, participants, & measurements All patients training for Home Hemodialysis at seven Canadian hospitals were assessed for eligibility, and demographic information and access type was collected on everyone. Patients who consented to participate were randomized to buttonhole or stepladder cannulation technique. Time to train for Home Hemodialysis, pain scores on cannulation, and complications over 12 months was recorded. For eligible but not randomized patients, reasons for not participating in the trial were documented. Results Patient recruitment was November 2013 to November 2015. During this time, 158 patients began training for Home Hemodialysis, and 108 were ineligible for the trial. Diabetes mellitus as a cause of ESKD (31% versus 12%) and central venous catheter use (74% versus 6%) were more common in ineligible patients. Of the 50 eligible patients, 14 patients from four out of seven sites consented to participate in the study (28%). The most common reason for declining to participate was a strong preference for a particular cannulation technique (33%). Patients randomized to buttonhole versus stepladder cannulation required a shorter time to complete Home Hemodialysis training. We did not observe a reduction in cannulation pain or complications with the buttonhole method. Data linkages for a formal cost analysis were not conducted. Conclusions We were unable to demonstrate the feasibility of conducting a randomized, controlled trial of buttonhole versus stepladder cannulation in Canada with a sufficient number of patients on Home Hemodialysis to be able to draw meaningful conclusions.

Karthik K Tennankore - One of the best experts on this subject based on the ideXlab platform.

  • Home Hemodialysis and peritoneal dialysis patient and technique survival in canada
    Kidney International Reports, 2020
    Co-Authors: Annieclaire Nadeaufredette, Karthik K Tennankore, Jeffrey Perl, Joanne M Bargman, David W Johnson, Christopher T Chan
    Abstract:

    Abstract Introduction As interest for Home dialysis is growing, knowledge of comparative clinical outcomes between peritoneal dialysis (PD) and Home Hemodialysis (HHD) would help better inform shared decision-making with patients and caregivers during modality discussion. This study aimed to assess differences in risk of mortality and technique failure in an incident Home dialysis cohort, and, specifically, assess change in this association through eras. Methods All adults patients initiating PD or HHD, in Canada (excluding Quebec), within 365 days after kidney replacement therapy (KRT) initiation between 2000 and 2013 were included (administrative censoring December 31, 2014). Mortality and treatment failure (transfer to another modality for >90 days or death) were assessed in a multivariable Cox proportional hazard model, with pre-specified stratification based on the year of KRT initiation. Results The study included 959 HHD and 15,469 PD patients. Compared with incident PD, incident HHD was associated with a lower risk of mortality (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.53-0.78) and treatment failure (aHR 0.52, 95% CI 0.45-0.60). These lower risks of mortality with HHD were more pronounced for older cohorts (2000-2005 aHR 0.47, 95% CI 0.31-0.70; 2006-2010 aHR 0.70, 95% CI 0.54-0.89) and not significantly different in the most recent era (2011-2013 aHR 0.86, 95% CI 0.51-1.47). Conclusion In incident Canadian KRT patients, HHD was associated with appreciably lower risks of mortality and treatment failure compared to PD, although this association appeared to be attenuated in the most contemporary era.

  • short daily nocturnal and conventional Home Hemodialysis have similar patient and treatment survival
    Kidney International, 2018
    Co-Authors: Christopher T Chan, Karthik K Tennankore, Jeffrey Perl, Ron Wald
    Abstract:

    Home Hemodialysis (HHD) has many benefits, but less is known about relative outcomes when comparing different Home-based Hemodialysis modalities. Here, we compare patient and treatment survival for patients receiving short daily HHD (2-3 hours/5 plus sessions per week), nocturnal HHD (6-8 hours/5 plus sessions per week) and conventional HHD (3-6 hours/2-4 sessions per week). A nationally representative cohort of Canadian HHD patients from 1996-2012 was studied. The primary outcome was death or treatment failure (defined as a permanent return to in-center Hemodialysis or peritoneal dialysis) using an intention to treat analysis and death-censored treatment failure as a secondary outcome. The cohort consisted of 600, 508 and 202 patients receiving conventional, nocturnal, and short daily HHD, respectively. Conventional-HHD patients were more likely to use dialysis catheter access (43%) versus nocturnal or short daily HHD (32% and 31%, respectively). Although point estimates were in favor of both therapies, after multivariable adjustment for patient and center factors, there was no statistically significant reduction in the relative hazard for the death/treatment failure composite comparing nocturnal to conventional HHD (hazard ratio 0.83 [95% confidence interval 0.66-1.03]) or short daily to conventional HHD (0.84, 0.63-1.12). Among those with information on vascular access, patients receiving nocturnal HHD had a relative improvement in death-censored treatment survival (0.75, 0.57-0.98). Thus, in this national cohort of HHD patients, those receiving short daily and nocturnal HHD had similar patient/treatment survival compared with patients receiving conventional HHD.

  • temporal trends and factors associated with Home Hemodialysis technique survival in canada
    Clinical Journal of The American Society of Nephrology, 2017
    Co-Authors: Jeffrey Perl, Karthik K Tennankore, Christopher T Chan
    Abstract:

    Background and objectives The last 15 years has seen growth in Home Hemodialysis (HD) utilization in Canada owing to reports of improved outcomes relative to patients on conventional in-center HD. What effect growth has had on Home HD technique and patient survival during this period is not known. Design, settings, participants, & measurements We compared the risk of Home HD technique failure, mortality, and the composite outcome among three incident cohorts of patients on Home HD in Canada: 1996–2002, 2003–2007, and 2008–2012. A multivariable piece-wise exponential model was used to evaluate all outcomes using inverse probability of treatment and censoring weights. Results A total of 1869 incident patients on Home HD were identified from the Canadian Organ Replacement Register. Relative to those treated between 2003 and 2007 (n=568), the risk of Home HD technique failure was similar between patients treated between 1996 and 2002 (n=233; adjusted hazard ratio [AHR], 1.39; 95% confidence interval [95% CI], 0.78 to 2.46) but higher among incident patients on Home HD treated between 2008 and 2012 (n=1068; AHR, 1.51; 95% CI, 1.06 to 2.15). Relative to patients treated between 2003 and 2007, adjusted mortality was similar among those treated between 2008 and 2012 (AHR, 0.83; 95% CI, 0.58 to 1.19) and those treated between 1996 and 2002 (AHR, 0.67; 95% CI, 0.38 to 1.21). The risk of the composite outcome of death and technique failure was similar across cohorts, as was the risk of receiving a kidney transplant. Increasing age, diabetes as a comorbidity, and smoking status were associated with an increased risk of death as well as the composite outcome. Medium-sized facilities had a lower risk of death, technique failure, and the composite outcome compared with larger facilities. Conclusions A higher risk of technique failure was seen in the most contemporary era. Further characterization of the risk factors for, and causes of technique failure is needed to develop strategies to improve patient retention on Home HD.

  • vascular access type and patient and technique survival in Home Hemodialysis patients the canadian organ replacement register
    American Journal of Kidney Diseases, 2016
    Co-Authors: Jeffrey Perl, Karthik K Tennankore, Ron Wald, Sharon J Nessim, Louise Moist, Christopher T Chan
    Abstract:

    Background While central venous catheter (CVC) use has expanded Home Hemodialysis (HHD) eligibility to many patients who may be unable to self-cannulate an arteriovenous (AV) access, the association between CVC use and mortality has not been directly examined among HHD patients. Study Design Registry-based retrospective observational cohort study. Setting & Participants Incident HHD patients in The Canadian Organ Replacement Register who had information for vascular access type (CVC vs AV access) within the first year of HHD therapy initiation. Predictor Use of a CVC versus an AV access (AV fistula or graft) within the first year of HHD therapy initiation. Outcome The composite of all-cause mortality and technique failure (long-term transfer to an alternate dialysis modality). A Cox proportional hazards model was used to evaluate the adjusted composite outcome and each outcome separately. Results 1,869 patients initiated HHD therapy in Canada in 1996 to 2012, of whom 1,217 had an access type recorded within the first year of HHD therapy initiation. Compared to CVC use (n=523) and during a median follow-up of 513 and 427 days for AV access and CVC patients, respectively, AV access use (n=694) was associated with lower risk for the composite event of death and technique failure (490 events; adjusted HR, 0.78; 95% CI, 0.64-0.94) and lower adjusted all-cause mortality (129 deaths; adjusted HR, 0.63; 95% CI, 0.43-0.91); the risk for technique failure was nominally lower, but this result was not statistically significant (361 events; adjusted HR, 0.84; 95% CI, 0.67-1.05). Results were robust to sensitivity analyses and after missing data imputation. Limitations Missing information for vascular access type (n=659[35% of patients]) and lack of information for longitudinal changes in vascular access type. Conclusions Compared to CVC use, AV access use was associated with superior survival. Minimizing CVC use and maximizing AV access use while addressing barriers to their placement and self-cannulation may improve HHD outcomes.

  • adverse technical events in Home Hemodialysis
    American Journal of Kidney Diseases, 2015
    Co-Authors: Karthik K Tennankore, Celine Dgama, Rose Faratro, Stella Fung, Elizabeth Wong, Christopher T Chan
    Abstract:

    Background There is a growing interest in Home Hemodialysis because of its clinical benefits. However, given that patients are responsible for performing a complex medical procedure at Home, adverse-event reporting is important to ensure patient safety. The purpose of this study was to describe adverse technical events in a large cohort of Home Hemodialysis patients. Study Design Retrospective cohort study. Setting & Participants All consecutive patients undergoing Home Hemodialysis at a large tertiary-care center from 1999 through 2011 (last follow-up, July 2012). Outcomes Overall rate of adverse technical events and number/rate of severe adverse events (defined as those requiring intervention). Results The cohort consisted of 202 patients with total follow-up of 757 patient-years. The cohort underwent a median of 5 dialysis treatments per week and 8 hours per session. 22 first adverse events and 7 recurrent events were identified. Adverse event rates were 0.049 per arteriovenous fistula access-year, 0.015 per arteriovenous graft access-year, and 0.022 per dialysis catheter access-year. Event rates per 1,000 dialysis treatments were 0.208, 0.068, and 0.087 for arteriovenous fistula, arteriovenous graft, and dialysis catheter access, respectively. Most adverse events were related to needle dislodgement (n=18) or air embolism (n=6). 8 adverse events resulted in emergency department visits and 5 required hospital admission. The rate of severe adverse events was 0.009 per patient-year of Home Hemodialysis and 0.038 per 1,000 dialysis treatments. Interventions included 3 blood transfusions, 2 catheter changes, 1 use of intravenous fluids, and 1 need for urgent dialysis. Attempts were made to retrain or review the technique in all patients with a first adverse event. Limitations Events that were not severe may have been under-reported by patients. Conclusions Serious adverse technical events in Home Hemodialysis are relatively rare. Strategies to further prevent these events may include patient retraining and periodic vascular access technique audit.

Jeffrey Perl - One of the best experts on this subject based on the ideXlab platform.

  • Home Hemodialysis and peritoneal dialysis patient and technique survival in canada
    Kidney International Reports, 2020
    Co-Authors: Annieclaire Nadeaufredette, Karthik K Tennankore, Jeffrey Perl, Joanne M Bargman, David W Johnson, Christopher T Chan
    Abstract:

    Abstract Introduction As interest for Home dialysis is growing, knowledge of comparative clinical outcomes between peritoneal dialysis (PD) and Home Hemodialysis (HHD) would help better inform shared decision-making with patients and caregivers during modality discussion. This study aimed to assess differences in risk of mortality and technique failure in an incident Home dialysis cohort, and, specifically, assess change in this association through eras. Methods All adults patients initiating PD or HHD, in Canada (excluding Quebec), within 365 days after kidney replacement therapy (KRT) initiation between 2000 and 2013 were included (administrative censoring December 31, 2014). Mortality and treatment failure (transfer to another modality for >90 days or death) were assessed in a multivariable Cox proportional hazard model, with pre-specified stratification based on the year of KRT initiation. Results The study included 959 HHD and 15,469 PD patients. Compared with incident PD, incident HHD was associated with a lower risk of mortality (adjusted hazard ratio [aHR] 0.64, 95% confidence interval [CI] 0.53-0.78) and treatment failure (aHR 0.52, 95% CI 0.45-0.60). These lower risks of mortality with HHD were more pronounced for older cohorts (2000-2005 aHR 0.47, 95% CI 0.31-0.70; 2006-2010 aHR 0.70, 95% CI 0.54-0.89) and not significantly different in the most recent era (2011-2013 aHR 0.86, 95% CI 0.51-1.47). Conclusion In incident Canadian KRT patients, HHD was associated with appreciably lower risks of mortality and treatment failure compared to PD, although this association appeared to be attenuated in the most contemporary era.

  • a comparison of technique survival in canadian peritoneal dialysis and Home Hemodialysis patients
    Nephrology Dialysis Transplantation, 2019
    Co-Authors: Emilie Trinh, Jeffrey Perl, Annieclaire Nadeaufredette, James A Hanley, Christopher T Chan
    Abstract:

    Background High discontinuation rates remain a challenge for Home Hemodialysis (HHD) and peritoneal dialysis (PD). We compared technique failure risks among Canadian patients receiving HHD and PD. Methods Using the Canadian Organ Replacement Register, we studied adult patients who initiated HHD or PD within 1 year of beginning dialysis between 2000 and 2012, with follow-up until 31 December 2013. Technique failure was defined as a transfer to any alternative modality for a period of ≥60 days. Technique survival between HHD and PD was compared using a Fine and Gray competing risk model. We also examined the time dependence of technique survival, the association of patient characteristics with technique failure and causes of technique failure. Results Between 2000 and 2012, 15 314 patients were treated with a Home dialysis modality within 1 year of dialysis initiation: 14 461 on PD and 853 on HHD. Crude technique failure rates were highest during the first year of therapy for both Home modalities. During the entire period of follow-up, technique failure was lower with HHD compared with PD (adjusted hazard ratio = 0.79; 95% confidence interval 0.69-0.90). However, the relative technique failure risk was not proportional over time and the beneficial association with HHD was only apparent after the first year of dialysis. Comparisons also varied among subgroups and the superior technique survival associated with HHD relative to PD was less pronounced in more recent years and among older patients. Predictors of technique failure also differed between modalities. While obesity, smoking and small facility size were associated with higher technique failure in both PD and HHD, the association with age and gender differed. Furthermore, the majority of discontinuation occurred for medical reasons in PD (38%), while the majority of HHD patients experienced technique failure due to social reasons or inadequate resources (50%). Conclusions In this Canadian study of Home dialysis patients, HHD was associated with better technique survival compared with PD. However, patterns of technique failure differed significantly among these modalities. Strategies to improve patient retention across all Home dialysis modalities are needed.

  • short daily nocturnal and conventional Home Hemodialysis have similar patient and treatment survival
    Kidney International, 2018
    Co-Authors: Christopher T Chan, Karthik K Tennankore, Jeffrey Perl, Ron Wald
    Abstract:

    Home Hemodialysis (HHD) has many benefits, but less is known about relative outcomes when comparing different Home-based Hemodialysis modalities. Here, we compare patient and treatment survival for patients receiving short daily HHD (2-3 hours/5 plus sessions per week), nocturnal HHD (6-8 hours/5 plus sessions per week) and conventional HHD (3-6 hours/2-4 sessions per week). A nationally representative cohort of Canadian HHD patients from 1996-2012 was studied. The primary outcome was death or treatment failure (defined as a permanent return to in-center Hemodialysis or peritoneal dialysis) using an intention to treat analysis and death-censored treatment failure as a secondary outcome. The cohort consisted of 600, 508 and 202 patients receiving conventional, nocturnal, and short daily HHD, respectively. Conventional-HHD patients were more likely to use dialysis catheter access (43%) versus nocturnal or short daily HHD (32% and 31%, respectively). Although point estimates were in favor of both therapies, after multivariable adjustment for patient and center factors, there was no statistically significant reduction in the relative hazard for the death/treatment failure composite comparing nocturnal to conventional HHD (hazard ratio 0.83 [95% confidence interval 0.66-1.03]) or short daily to conventional HHD (0.84, 0.63-1.12). Among those with information on vascular access, patients receiving nocturnal HHD had a relative improvement in death-censored treatment survival (0.75, 0.57-0.98). Thus, in this national cohort of HHD patients, those receiving short daily and nocturnal HHD had similar patient/treatment survival compared with patients receiving conventional HHD.

  • temporal trends and factors associated with Home Hemodialysis technique survival in canada
    Clinical Journal of The American Society of Nephrology, 2017
    Co-Authors: Jeffrey Perl, Karthik K Tennankore, Christopher T Chan
    Abstract:

    Background and objectives The last 15 years has seen growth in Home Hemodialysis (HD) utilization in Canada owing to reports of improved outcomes relative to patients on conventional in-center HD. What effect growth has had on Home HD technique and patient survival during this period is not known. Design, settings, participants, & measurements We compared the risk of Home HD technique failure, mortality, and the composite outcome among three incident cohorts of patients on Home HD in Canada: 1996–2002, 2003–2007, and 2008–2012. A multivariable piece-wise exponential model was used to evaluate all outcomes using inverse probability of treatment and censoring weights. Results A total of 1869 incident patients on Home HD were identified from the Canadian Organ Replacement Register. Relative to those treated between 2003 and 2007 (n=568), the risk of Home HD technique failure was similar between patients treated between 1996 and 2002 (n=233; adjusted hazard ratio [AHR], 1.39; 95% confidence interval [95% CI], 0.78 to 2.46) but higher among incident patients on Home HD treated between 2008 and 2012 (n=1068; AHR, 1.51; 95% CI, 1.06 to 2.15). Relative to patients treated between 2003 and 2007, adjusted mortality was similar among those treated between 2008 and 2012 (AHR, 0.83; 95% CI, 0.58 to 1.19) and those treated between 1996 and 2002 (AHR, 0.67; 95% CI, 0.38 to 1.21). The risk of the composite outcome of death and technique failure was similar across cohorts, as was the risk of receiving a kidney transplant. Increasing age, diabetes as a comorbidity, and smoking status were associated with an increased risk of death as well as the composite outcome. Medium-sized facilities had a lower risk of death, technique failure, and the composite outcome compared with larger facilities. Conclusions A higher risk of technique failure was seen in the most contemporary era. Further characterization of the risk factors for, and causes of technique failure is needed to develop strategies to improve patient retention on Home HD.

  • vascular access type and patient and technique survival in Home Hemodialysis patients the canadian organ replacement register
    American Journal of Kidney Diseases, 2016
    Co-Authors: Jeffrey Perl, Karthik K Tennankore, Ron Wald, Sharon J Nessim, Louise Moist, Christopher T Chan
    Abstract:

    Background While central venous catheter (CVC) use has expanded Home Hemodialysis (HHD) eligibility to many patients who may be unable to self-cannulate an arteriovenous (AV) access, the association between CVC use and mortality has not been directly examined among HHD patients. Study Design Registry-based retrospective observational cohort study. Setting & Participants Incident HHD patients in The Canadian Organ Replacement Register who had information for vascular access type (CVC vs AV access) within the first year of HHD therapy initiation. Predictor Use of a CVC versus an AV access (AV fistula or graft) within the first year of HHD therapy initiation. Outcome The composite of all-cause mortality and technique failure (long-term transfer to an alternate dialysis modality). A Cox proportional hazards model was used to evaluate the adjusted composite outcome and each outcome separately. Results 1,869 patients initiated HHD therapy in Canada in 1996 to 2012, of whom 1,217 had an access type recorded within the first year of HHD therapy initiation. Compared to CVC use (n=523) and during a median follow-up of 513 and 427 days for AV access and CVC patients, respectively, AV access use (n=694) was associated with lower risk for the composite event of death and technique failure (490 events; adjusted HR, 0.78; 95% CI, 0.64-0.94) and lower adjusted all-cause mortality (129 deaths; adjusted HR, 0.63; 95% CI, 0.43-0.91); the risk for technique failure was nominally lower, but this result was not statistically significant (361 events; adjusted HR, 0.84; 95% CI, 0.67-1.05). Results were robust to sensitivity analyses and after missing data imputation. Limitations Missing information for vascular access type (n=659[35% of patients]) and lack of information for longitudinal changes in vascular access type. Conclusions Compared to CVC use, AV access use was associated with superior survival. Minimizing CVC use and maximizing AV access use while addressing barriers to their placement and self-cannulation may improve HHD outcomes.

Allan J Collins - One of the best experts on this subject based on the ideXlab platform.

  • relative risk of Home Hemodialysis attrition in patients using a telehealth platform
    Hemodialysis International, 2018
    Co-Authors: Eric D Weinhandl, Allan J Collins
    Abstract:

    INTRODUCTION Home Hemodialysis (HHD) facilitates increased treatment frequency, which may improve patient outcomes. However, attrition due to technique failure limits the clinical effectiveness of the modality. Nx2me Connected Health is a telehealth platform that enables ongoing assessment of HHD patients using NxStage equipment, and that may reduce patient burden. We aimed to assess whether use of Nx2me was associated with risk of HHD attrition. METHODS We compared risks of all-cause attrition, dialysis cessation (i.e., death or transplant), and technique failure in Nx2me users and matched control patients, using a retrospective cohort study. We also compared the likelihood of HHD training graduation in patients who initiated use of Nx2me during training with the likelihood in matched control patients. Matching factors included date of HHD initiation, NxStage treatment duration at initiation of follow-up, and prescribed treatment frequency. We used stratified Fine-Gray and Cox regression to compare risks, with adjustment for demographic factors and vascular access modality, and stratification by matched cluster. FINDINGS We identified 606 Nx2me users; 49.5% initiated use of Nx2me in <3 months after initiation of HHD with NxStage equipment. Adjusted hazard ratios (AHRs) of all-cause attrition, dialysis cessation, and technique failure were 0.80 (95% confidence interval, 0.68-0.95), 1.10 (0.86-1.41), and 0.71 (0.57-0.87), respectively, for Nx2me users vs. matched controls. AHRs were similar in patients who initiated use of Nx2me in <3 months after initiation of HHD. The AHR of HHD training graduation was 1.61 (1.10-2.36) in patients who initiated use of Nx2me within 2 weeks of training initiation vs. matched controls. DISCUSSION Use of Nx2me was associated with lower risk of all-cause attrition, lower risk of technique failure, and higher likelihood of HHD training graduation. Further studies are needed to identify the mechanisms by which use of a telehealth platform may improve clinical outcomes and reduce patient burden.

  • mortality hospitalization and technique failure in daily Home Hemodialysis and matched peritoneal dialysis patients a matched cohort study
    American Journal of Kidney Diseases, 2016
    Co-Authors: Eric D Weinhandl, David T Gilbertson, Allan J Collins
    Abstract:

    Background Use of Home dialysis is growing in the United States, but few direct comparisons of major clinical outcomes on daily Home Hemodialysis (HHD) versus peritoneal dialysis (PD) exist. Study Design Matched cohort study. Setting & Participants We matched 4,201 new HHD patients in 2007 to 2010 with 4,201 new PD patients from the US Renal Data System database. Predictor Daily HHD versus PD. Outcomes Relative mortality, hospitalization, and technique failure. Results Mean time from end-stage renal disease onset to Home dialysis therapy initiation was 44.6 months for HHD and 44.3 months for PD patients. In intention-to-treat analysis, HHD was associated with 20% lower risk for all-cause mortality (HR, 0.80; 95% CI, 0.73-0.87), 8% lower risk for all-cause hospitalization (HR, 0.92; 95% CI, 0.89-0.95), and 37% lower risk for technique failure (HR, 0.63; 95% CI, 0.58-0.68), all relative to PD. In the subset of 1,368 patients who initiated Home dialysis therapy within 6 months of end-stage renal disease onset, HHD was associated with similar risk for all-cause mortality (HR, 0.95; 95% CI, 0.80-1.13), similar risk for all-cause hospitalization (HR, 0.96; 95% CI, 0.88-1.05), and 30% lower risk for technique failure (HR, 0.70; 95% CI, 0.60-0.82). Regarding hospitalization, risk comparisons favored HHD for cardiovascular disease and dialysis access infection and PD for bloodstream infection. Limitations Matching unlikely to reduce confounding attributable to unmeasured factors, including residual kidney function; lack of data regarding dialysis frequency, duration, and dose in daily HHD patients and frequency and solution in PD patients; diagnosis codes used to classify admissions. Conclusions These data suggest that relative to PD, daily HHD is associated with decreased mortality, hospitalization, and technique failure. However, risks for mortality and hospitalization were similar with these modalities in new dialysis patients. The interaction between modality and end-stage renal disease duration at Home dialysis therapy initiation should be investigated further.

  • hospitalization in daily Home Hemodialysis and matched thrice weekly in center Hemodialysis patients
    American Journal of Kidney Diseases, 2015
    Co-Authors: Eric D Weinhandl, David T Gilbertson, Kimberly Nieman, Allan J Collins
    Abstract:

    Background Cardiovascular disease is a common cause of hospitalization in dialysis patients. Daily Hemodialysis improves some parameters of cardiovascular function, but whether it associates with lower hospitalization risk is unclear. Study Design Observational cohort study using US Renal Data System data. Setting & Participants Medicare-enrolled daily (5 or 6 sessions weekly) Home Hemodialysis (HHD) patients initiating NxStage System One use from January 1, 2006, through December 31, 2009, and contemporary thrice-weekly in-center Hemodialysis patients, matched 5 to 1. Predictor Daily HHD or thrice-weekly in-center Hemodialysis. Outcomes & Measurements All-cause and cause-specific hospital admissions, hospital readmissions, and hospital days assessed from Medicare Part A claims. Results For 3,480 daily HHD and 17,400 thrice-weekly in-center Hemodialysis patients in intention-to-treat analysis, the HR of all-cause admission for daily HHD versus in-center Hemodialysis was 1.01 (95%CI, 0.98-1.03). Cause-specific admission HRs were 0.89 (95%CI, 0.86-0.93) for cardiovascular disease, 1.18 (95%CI, 1.13-1.23) for infection, 1.01 (95%CI, 0.93-1.09) for vascular access dysfunction, and 1.02 (95%CI, 0.99-1.06) for other morbidity. Regarding cardiovascular disease, first admission and readmission HRs for daily HHD versus in-center Hemodialysis were 0.91 and 0.87, respectively. Regarding infection, first admission and readmission HRs were 1.35 and 1.03, respectively. Protective associations of daily HHD with heart failure and hypertensive disease were most pronounced, as were adverse associations of daily HHD with bacteremia/sepsis, cardiac infection, osteomyelitis, and vascular access infection. Limitations Results may be confounded by unmeasured factors, including vascular access type; information about dialysis frequency, duration, and dose was lacking; causes of admission may be misclassified; results may not apply to patients without Medicare coverage. Conclusions All-cause hospitalization risk was similar in daily HHD and thrice-weekly in-center Hemodialysis patients. However, risk of cardiovascular-related admission was lower with daily HHD, and risk of infection-related admission was higher. More attention should be afforded to infection in HHD patients.

  • survival in daily Home Hemodialysis and matched thrice weekly in center Hemodialysis patients
    Journal of The American Society of Nephrology, 2012
    Co-Authors: Eric D Weinhandl, Jiannong Liu, David T Gilbertson, Thomas J Arneson, Allan J Collins
    Abstract:

    Frequent Hemodialysis improves cardiovascular surrogates and quality-of-life indicators, but its effect on survival remains unclear. We used a matched-cohort design to assess relative mortality in daily Home Hemodialysis and thrice-weekly in-center Hemodialysis patients between 2005 and 2008. We matched 1873 Home Hemodialysis patients with 9365 in-center patients (i.e., 1:5 ratio) selected from the prevalent population in the US Renal Data System database. Matching variables included first date of follow-up, demographic characteristics, and measures of disease severity. The cumulative incidence of death was 19.2% and 21.7% in the Home Hemodialysis and in-center patients, respectively. In the intention-to-treat analysis, Home Hemodialysis associated with a 13% lower risk for all-cause mortality than in-center Hemodialysis (hazard ratio [HR], 0.87; 95% confidence interval [95% CI], 0.78-0.97). Cause-specific mortality HRs were 0.92 (95% CI, 0.78-1.09) for cardiovascular disease, 1.13 (95% CI, 0.84-1.53) for infection, 0.63 (95% CI, 0.41-0.95) for cachexia/dialysis withdrawal, 1.06 (95% CI, 0.81-1.37) for other specified cause, and 0.59 (95% CI, 0.44-0.79) for unknown cause. Findings were similar using as-treated analyses. We did not detect statistically significant evidence of heterogeneity of treatment effects in subgroup analyses. In summary, these data suggest that relative to thrice-weekly in-center Hemodialysis, daily Home Hemodialysis associates with modest improvements in survival. Continued surveillance should strengthen inference about causes of mortality and determine whether treatment effects are homogeneous throughout the dialysis population.

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  • a systematic approach to promoting Home Hemodialysis during end stage kidney disease
    Kidney, 2020
    Co-Authors: Robert S Lockridge, Michael A Kraus, Eric D Weinhandl, Joel D Glickman, Leslie Spry, Martin A Schreiber, Prayus Tailor, Michelle Carver, Brent W Miller
    Abstract:

    Home dialysis has garnered much attention since the advent of the Advancing American Kidney Health initiative. For many patients and nephrologists, Home dialysis and peritoneal dialysis are synonymous. However, Home Hemodialysis (HHD) should not be forgotten. Since 2004, HHD has grown more rapidly than other dialytic modalities. The cardinal feature of HHD is customizability of treatment intensity, which can be titrated to address the vexing problems of volume and pressure loading during interdialytic gaps and ultrafiltration intensity during each Hemodialysis session. Growing HHD utilization requires commitment to introducing patients to the modality throughout the course of ESKD. In this article, we describe a set of strategies for introducing HHD concepts and equipment. First, patients initiating dialysis may attend a transitional care unit, which offers an educational program about all dialytic modalities during 3–5 weeks of in-facility Hemodialysis, possibly using HHD equipment. Second, prevalent patients on Hemodialysis may participate in “trial-run” programs, which allow patients to experience increased treatment frequency and HHD equipment for several weeks, but without the overt commitment of initiating HHD training. In both models, perceived barriers to HHD—including fear of equipment, anxiety about self-cannulation, catheter dependence, and the absence of a care partner—can be addressed in a supportive setting. Third, patients on peritoneal dialysis who are nearing a transition to Hemodialysis may be encouraged to consider a Home-to-Home transition (i.e., from peritoneal dialysis to HHD). Taken together, these strategies represent a systematic approach to growing HHD utilization in multiple phenotypes of patients on dialysis. With the feature of facilitating intensive Hemodialysis, HHD can be a key not only to satiating demand for Home dialysis, but also to improving the health of patients on dialysis.

  • Home Hemodialysis treatment and outcomes retrospective analysis of the knowledge to improve Home dialysis network in europe kihdney cohort
    BMC Nephrology, 2018
    Co-Authors: Shashidhar Cherukuri, Eric D Weinhandl, Giacomo Colussi, Roberto Corciulo, Hafedh Fessi, Maxence Ficheux, Maria Slon, Maria Auxiliadora Bajo, Natalie Borman
    Abstract:

    Utilization of Home Hemodialysis (HHD) is low in Europe. The Knowledge to Improve Home Dialysis Network in Europe (KIHDNEy) is a multi-center study of HHD patients who have used a transportable Hemodialysis machine that employs a low volume of lactate-buffered, ultrapure dialysate per session. In this retrospective cohort analysis, we describe patient factors, HHD prescription factors, and biochemistry and medication use during the first 6 months of HHD and rates of clinical outcomes thereafter. Using a standardized digital form, we recorded data from 7 centers in 4 Western European countries. We retained patients who completed ≥6 months of HHD. We summarized patient and HHD prescription factors with descriptive statistics and used mixed modeling to assess trends in biochemistry and medication use. We also estimated long-term rates of kidney transplant and death. We identified 129 HHD patients; 104 (81%) were followed for ≥6 months. Mean age was 49 years and 66% were male. Over 70% of patients were prescribed 6 sessions per week, and the mean treatment duration was 15.0 h per week. Median HHD training duration was 2.5 weeks. Mean standard Kt/Vurea was nearly 2.7 at months 3 and 6. Pre-dialysis biochemistry was generally stable. Between baseline and month 6, mean serum bicarbonate increased from 23.1 to 24.1 mmol/L (P = 0.01), mean serum albumin increased from 36.8 to 37.8 g/L (P = 0.03), mean serum C-reactive protein increased from 7.3 to 12.4 mg/L (P = 0.05), and mean serum potassium decreased from 4.80 to 4.59 mmol/L (P = 0.01). Regarding medication use, the mean number of antihypertensive medications fell from 1.46 agents per day at HHD initiation to 1.01 agents per day at 6 months (P < 0.001), but phosphate binder use and erythropoiesis-stimulating agent dose were stable. Long-term rates of kidney transplant and death were 15.3 and 5.4 events per 100 patient-years, respectively. Intensive HHD with low-flow dialysate delivers adequate urea clearance and good biochemical outcomes in Western European patients. Intensive HHD coincided with a large decrease in antihypertensive medication use. With relatively rapid training, HHD should be considered in more patients.

  • relative risk of Home Hemodialysis attrition in patients using a telehealth platform
    Hemodialysis International, 2018
    Co-Authors: Eric D Weinhandl, Allan J Collins
    Abstract:

    INTRODUCTION Home Hemodialysis (HHD) facilitates increased treatment frequency, which may improve patient outcomes. However, attrition due to technique failure limits the clinical effectiveness of the modality. Nx2me Connected Health is a telehealth platform that enables ongoing assessment of HHD patients using NxStage equipment, and that may reduce patient burden. We aimed to assess whether use of Nx2me was associated with risk of HHD attrition. METHODS We compared risks of all-cause attrition, dialysis cessation (i.e., death or transplant), and technique failure in Nx2me users and matched control patients, using a retrospective cohort study. We also compared the likelihood of HHD training graduation in patients who initiated use of Nx2me during training with the likelihood in matched control patients. Matching factors included date of HHD initiation, NxStage treatment duration at initiation of follow-up, and prescribed treatment frequency. We used stratified Fine-Gray and Cox regression to compare risks, with adjustment for demographic factors and vascular access modality, and stratification by matched cluster. FINDINGS We identified 606 Nx2me users; 49.5% initiated use of Nx2me in <3 months after initiation of HHD with NxStage equipment. Adjusted hazard ratios (AHRs) of all-cause attrition, dialysis cessation, and technique failure were 0.80 (95% confidence interval, 0.68-0.95), 1.10 (0.86-1.41), and 0.71 (0.57-0.87), respectively, for Nx2me users vs. matched controls. AHRs were similar in patients who initiated use of Nx2me in <3 months after initiation of HHD. The AHR of HHD training graduation was 1.61 (1.10-2.36) in patients who initiated use of Nx2me within 2 weeks of training initiation vs. matched controls. DISCUSSION Use of Nx2me was associated with lower risk of all-cause attrition, lower risk of technique failure, and higher likelihood of HHD training graduation. Further studies are needed to identify the mechanisms by which use of a telehealth platform may improve clinical outcomes and reduce patient burden.

  • mortality hospitalization and technique failure in daily Home Hemodialysis and matched peritoneal dialysis patients a matched cohort study
    American Journal of Kidney Diseases, 2016
    Co-Authors: Eric D Weinhandl, David T Gilbertson, Allan J Collins
    Abstract:

    Background Use of Home dialysis is growing in the United States, but few direct comparisons of major clinical outcomes on daily Home Hemodialysis (HHD) versus peritoneal dialysis (PD) exist. Study Design Matched cohort study. Setting & Participants We matched 4,201 new HHD patients in 2007 to 2010 with 4,201 new PD patients from the US Renal Data System database. Predictor Daily HHD versus PD. Outcomes Relative mortality, hospitalization, and technique failure. Results Mean time from end-stage renal disease onset to Home dialysis therapy initiation was 44.6 months for HHD and 44.3 months for PD patients. In intention-to-treat analysis, HHD was associated with 20% lower risk for all-cause mortality (HR, 0.80; 95% CI, 0.73-0.87), 8% lower risk for all-cause hospitalization (HR, 0.92; 95% CI, 0.89-0.95), and 37% lower risk for technique failure (HR, 0.63; 95% CI, 0.58-0.68), all relative to PD. In the subset of 1,368 patients who initiated Home dialysis therapy within 6 months of end-stage renal disease onset, HHD was associated with similar risk for all-cause mortality (HR, 0.95; 95% CI, 0.80-1.13), similar risk for all-cause hospitalization (HR, 0.96; 95% CI, 0.88-1.05), and 30% lower risk for technique failure (HR, 0.70; 95% CI, 0.60-0.82). Regarding hospitalization, risk comparisons favored HHD for cardiovascular disease and dialysis access infection and PD for bloodstream infection. Limitations Matching unlikely to reduce confounding attributable to unmeasured factors, including residual kidney function; lack of data regarding dialysis frequency, duration, and dose in daily HHD patients and frequency and solution in PD patients; diagnosis codes used to classify admissions. Conclusions These data suggest that relative to PD, daily HHD is associated with decreased mortality, hospitalization, and technique failure. However, risks for mortality and hospitalization were similar with these modalities in new dialysis patients. The interaction between modality and end-stage renal disease duration at Home dialysis therapy initiation should be investigated further.

  • hospitalization in daily Home Hemodialysis and matched thrice weekly in center Hemodialysis patients
    American Journal of Kidney Diseases, 2015
    Co-Authors: Eric D Weinhandl, David T Gilbertson, Kimberly Nieman, Allan J Collins
    Abstract:

    Background Cardiovascular disease is a common cause of hospitalization in dialysis patients. Daily Hemodialysis improves some parameters of cardiovascular function, but whether it associates with lower hospitalization risk is unclear. Study Design Observational cohort study using US Renal Data System data. Setting & Participants Medicare-enrolled daily (5 or 6 sessions weekly) Home Hemodialysis (HHD) patients initiating NxStage System One use from January 1, 2006, through December 31, 2009, and contemporary thrice-weekly in-center Hemodialysis patients, matched 5 to 1. Predictor Daily HHD or thrice-weekly in-center Hemodialysis. Outcomes & Measurements All-cause and cause-specific hospital admissions, hospital readmissions, and hospital days assessed from Medicare Part A claims. Results For 3,480 daily HHD and 17,400 thrice-weekly in-center Hemodialysis patients in intention-to-treat analysis, the HR of all-cause admission for daily HHD versus in-center Hemodialysis was 1.01 (95%CI, 0.98-1.03). Cause-specific admission HRs were 0.89 (95%CI, 0.86-0.93) for cardiovascular disease, 1.18 (95%CI, 1.13-1.23) for infection, 1.01 (95%CI, 0.93-1.09) for vascular access dysfunction, and 1.02 (95%CI, 0.99-1.06) for other morbidity. Regarding cardiovascular disease, first admission and readmission HRs for daily HHD versus in-center Hemodialysis were 0.91 and 0.87, respectively. Regarding infection, first admission and readmission HRs were 1.35 and 1.03, respectively. Protective associations of daily HHD with heart failure and hypertensive disease were most pronounced, as were adverse associations of daily HHD with bacteremia/sepsis, cardiac infection, osteomyelitis, and vascular access infection. Limitations Results may be confounded by unmeasured factors, including vascular access type; information about dialysis frequency, duration, and dose was lacking; causes of admission may be misclassified; results may not apply to patients without Medicare coverage. Conclusions All-cause hospitalization risk was similar in daily HHD and thrice-weekly in-center Hemodialysis patients. However, risk of cardiovascular-related admission was lower with daily HHD, and risk of infection-related admission was higher. More attention should be afforded to infection in HHD patients.