Nephrol Dial Transplant (2011) 26: 2302–2308
doi: 10.1093/ndt/gfq669
Advance Access publication 11 November 2010
Dedication of a nurse to educating suboptimal haemodialysis
starts improved transition to independent modalities of renal
replacement therapy
Jennifer Hanko, Jacek Jastrzebski, Cheryl Nieva, Leigh White, Guiyun Li and Nadia Zalunardo
Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
Correspondence and offprint requests to: Jennifer B. Hanko; E-mail: [email protected]
Abstract
Background. Haemodialysis (HD) initiation is unplanned
in up to 50% of patients, mainly due to late diagnosis and/
or late nephrology referral. In these patients, time does not
permit the multidisciplinary predialysis care that is associated with increased independent renal replacement therapy (RRT) modality choice and better access to kidney
transplantation. We established a Renal Triage Nurse
(RTN) position to educate suboptimal HD starts and to facilitate transition to independent modalities of RRT.
Methods. Adult patients starting HD from 1 January 2005
to 31 December 2008 with <180 days nephrology followup and surviving at least 180 days were included (suboptimal HD starts). The RTN educated suboptimal HD starts
beginning in December 2006. Patients initiating RRT via
the multidisciplinary predialysis clinic (MPC) were included for comparison. Multivariable logistic regression
was used to determine the association between being seen
by the RTN and achieving independent modalities of RRT.
Results. There were 176 patients: 78 suboptimal HD starts
(38 of these were educated by the RTN) and 98 patients
initiated RRT after a minimum 180-day follow-up at the
MPC. Of the RTN patients, 27.8% switched to independent RRT modalities (peritoneal dialysis n = 7, home
haemodialysis n = 1, transplant n = 2). RTN patients were
more likely to live alone (33.3% versus 10.8%, P = 0.02)
and to have cerebrovascular disease (25.0% versus 7.1%,
P = 0.03); however, adjusting for these variables, suboptimal
HD starts seen by the RTN were more likely to transition
to independent RRT (OR 3.75, 95% CI 1.08–13.05) than
those not seen. The proportion starting on an independent
modality via the MPC was 39.8%. The RTN achieved a
rate of independent RRT not statistically different to that
observed in patients starting RRT via the MPC (OR
0.74, 95% CI 0.19–2.94 in multivariable analysis).
Conclusions. Addition of the RTN to the HD care team
facilitated transition to independent modalities of RRT in
suboptimal HD starts. This standardized approach to the
care of such patients should be considered in HD units
where suboptimal HD starts are common.
Keywords: independent dialysis; peritoneal dialysis; predialysis
education; nurse educator; suboptimal haemodialysis start
Introduction
Despite the fact that 56% of nephrologists and renal nurses
view independent modalities of renal replacement therapy
(RRT) as best for their patients, at most only 15% of dialysis patients are on independent modalities worldwide [1].
This is undoubtedly related in part to the fact that dialysis
initiation is unplanned in up to 50% of patients, mainly due
to late diagnosis and/or late nephrology referral [2–5]. In
such cases, time does not permit the multidisciplinary predialysis care that is associated with increased independent
dialysis modality choice [i.e. peritoneal dialysis (PD) and
home haemodialysis (HHD)] and better access to kidney
transplantation [6–12].
Unplanned, or ‘suboptimal’, dialysis starts include patients diagnosed with end-stage renal disease (ESRD) during hospitalization, outpatients with a late diagnosis of
kidney disease and/or late referral to nephrology and outpatients known to nephrology who have an unexpectedly
rapid deterioration in kidney function or who are lost to
follow-up [5]. Their default initial dialysis modality is generally haemodialysis (HD) via a central venous catheter
(CVC), which is associated with an increased risk of infection, hospitalization and mortality compared to HD with an
arteriovenous fistula (AVF) or graft [9,13–15]. Furthermore, such patients often remain on conventional HD
and lose the potential benefits associated with independent
modalities of RRT including lifestyle benefits (e.g. treatment closer to home, improved dietary freedom and ability
to work), health benefits (particularly in the case of nocturnal HHD and early kidney transplantation) and cost savings to the heath care system [16–23].
The optimal approach to the care of suboptimal HD
starts is not addressed by currently available clinical practice guidelines which focus on patients with recognized
chronic kidney disease progressing at a rate that allows
© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
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Transition of suboptimal HD starts to independent RRT
timely education and advanced planning for RRT [24,25].
To address this important gap in patient care, we established
a ‘Renal Triage Nurse’ (RTN) position in our hospital-based
HD unit dedicated to the education of suboptimal HD
starts with the specific objective of facilitating transition
to independent modalities of RRT (i.e. PD, HHD and live
donor kidney transplantation).
Our approach to the care of suboptimal HD starts is presented in this report. To assess the effectiveness of this
model of care, we focused on the following major objectives: (i) to determine whether the RTN was able to increase the likelihood of transition to independent RRT
modalities and (ii) to compare the renal replacement modality of suboptimal HD starts educated by the RTN to that
of the patients educated by the multidisciplinary predialysis clinic (MPC).
Materials and methods
This was a retrospective cohort study of patients starting RRT at the Vancouver General Hospital (VGH), a tertiary care teaching hospital affiliated
with the University of British Columbia (Vancouver, Canada) with an inhospital HD unit accommodating 180 patients. For most patients, HD is
administered for 4 h, three times per week using high-flux dialysis membranes. Clinical and laboratory (e.g. haemoglobin and serum albumin)
data were collected prospectively for patients followed by the RTN. For
all others, data were abstracted by chart review and using PROMIS, an
electronic medical record for chronic kidney disease patients in the province of British Columbia.
Patient selection
Suboptimal HD start patients. All patients starting HD at VGH from 1
January 2005 to 31 December 2008 and surviving at least 180 days were
considered for inclusion. A minimum 180-day survival was used to select
for individuals living long enough to allow time for education and a potential modality switch. The RTN position was established on 1 December
2006. Suboptimal HD starts were defined as patients who started HD
within 180 days of initial outpatient consultation with a nephrologist, individuals who saw a nephrologist only once even if more than 180 days
elapsed between this visit and HD start date (indicating loss to follow-up
or unexpected deterioration in kidney function) and patients diagnosed
with ESRD during a hospital admission. Late referral is variably defined
in the literature at between 4 and 12 months from RRT start [2,3,25,26].
We chose 180 days based on our experience that this is the minimum time
required for education and creation of a functioning AVF for the majority
of patients choosing HD. All patients in this group commenced dialysis
via a CVC. If the initial catheter was a non-tunnelled line, patients transitioned to a tunnelled line within the first 2 weeks.
MPC patients. Patients initiating RRT via the MPC were included for
comparison of RRT modalities with patients educated by the RTN. The
personnel dedicated to patient care at the MPC included physician, nurse,
dietician, pharmacist and social worker. All patients with a minimum follow-up of 180 days at the MPC and initiating RRT (dialysis or live donor
kidney transplant) between 1 December 2006 (same date that RTN position was established) and 31 December 2008 were included.
Study exclusion criteria included acute kidney injury, previous RRT
(including kidney transplant) for any reason and patients transferred from
other health authorities.
Suboptimal HD start triage and education process
A weekly multidisciplinary HD meeting (nephrologist, HD unit charge
nurse, pharmacist, dietician, social worker, vascular access nurse) was established in 1997 to review incident HD patients with respect to blood
pressure, goal weight, medications, nutritional status, laboratory variables,
other pertinent medical issues (e.g. cardiovascular disease) and social circumstances impacting on care. The potential for modality switch was also
2303
considered; however, prior to the establishment of the RTN position, no
personnel was specifically dedicated to patient education regarding modality choice. In December 2006, with the support of the British
Columbia Provincial Renal Agency (BCPRA), the RTN position was
added to the team to address modality selection in suboptimal HD starts.
Suboptimal HD starts were referred by a nephrologist to the RTN upon
initiation of HD using a standardized referral form. The RTN usually met
with patients during their scheduled treatments in the hospital-based HD
unit. On occasion, further discussion was arranged outside of the patient’s
regular dialysis time, either in person or by telephone. The RTN assessed
and educated the patients as follows:
(1) Initial assessment: chart review; interview(s) with patient and, if relevant, next-of-kin/caregivers; and review of the assessments of other
team members (e.g. assessment of home life by the social worker).
(2) Suitability for independent modalities: advantages, potential barriers
and contraindications to independent RRT modalities were identified
using standardized criteria including the Match-D tool (designed specifically to aid assessment of suitability for home dialysis modalities)
[27].
(3) Education: during face-to-face meetings, the RTN assessed the patient’s
preferred learning style taking into account the patient’s language, literacy, education and their expressed preferences (e.g. web-based information versus reading material). Education was then tailored to the
individual with resources including individual counselling, written
material, audio/visual material, web browsing and group discussions.
Most resource materials were obtained from Baxter Healthcare, the
United States National Kidney Foundation and the Kidney Foundation
of Canada. In addition, all patients were given the opportunity to watch
a DVD produced by the BCPRA entitled ‘Patient to Patient: Kidney
Care in BC’. The DVD outlines RRT modalities and is available in
English, Cantonese, Mandarin, Punjabi and Tagalog.
(4) Modality choice: if no contraindications or significant barriers were
identified, patients were encouraged to consider independent modalities of RRT. The RTN initiated referral for PD catheter insertion, permanent HD vascular access creation, HHD assessment and/or kidney
transplant assessment as appropriate and in consultation with the
nephrologist.
(5) Follow-up: the RTN followed the patient until a long-term plan for
RRT was established.
Outcomes
The primary outcome of interest was the likelihood of suboptimal HD
starts switching to an independent RRT modality by 180 days after HD
start in patients assessed by the RTN versus those not assessed. Independent RRT modality was defined as PD, HHD or live donor kidney transplant (no patient received a deceased donor transplant). The secondary
outcome of interest was a comparison of the likelihood of independent
RRT modality (at 180 days) in the suboptimal HD starts educated by
the RTN versus that in the ‘planned’ starts initiating RRT via the MPC.
Statistical considerations
Baseline characteristics were summarized using proportions or mean
(standard deviation), and comparisons were made using the Chi-squared
or t test, as appropriate. The number of RTN visits and RTN time spent
per patient was summarized using median [interquartile range (IQR)]. For
outcomes expressed as proportions, comparisons were made using the
Chi-squared or Fisher’s exact test. Potential confounders for multivariable
analysis were determined based on a threshold statistical significance of
P ≤ 0.2 in univariate analyses. Two multivariable logistic regression analyses were performed: (i) comparison of RRT modality at 180 days in suboptimal HD starts seen by the RTN to those not seen by the RTN and (ii)
comparison of RRT modality of suboptimal HD starts seen by the RTN
(assessed at 180 days after HD start) to the first modality of patients initiating RRT via the MPC (followed for at least 180 days prior to RRT start).
All suboptimal HD starts after 1 December 2006 were seen by the
RTN except for 11 patients who were not seen due to transient lack of
staffing of the position. These patients were included in the ‘not seen
by RTN’ group. Analyses were repeated with and without these individuals to determine any effect on the outcomes of interest.
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J. Hanko et al.
Statistical analyses were performed using SAS version 9.3. All Pvalues were two tailed, and P-values < 0.05 were considered statistically
significant. This study was approved by our hospital Clinical Research
Ethics Board.
Results
During this 4-year study, 309 patients started RRT with
<180 days of follow-up by nephrology; all started HD
via a CVC as the initial modality. Many of these HD
starts were hospitalized patients with acute kidney injury
who recovered self-sustaining renal function (n = 139,
45%). Of the remainder, 57 patients (18.4%) died (most
of whom died during hospitalization complicated by acute
kidney injury), 16 patients (5.2%) withdrew from dialysis
and 19 patients (6.1%) were transferred to other hospitals
or lost to follow-up (Figure 1). The remaining 78 patients
remained on RRT at 180 days and were included in the
study as suboptimal HD starts. Of these suboptimal HD
starts, 52 patients (67%) were followed by a nephrologist
for <1 month or were diagnosed with ESRD during a hos-
pital admission, 11 (14%) were followed for 1–3 months,
14 (18%) were followed for 3–6 months and 1 patient saw
a nephrologist only once more than 6 months prior to HD
start.
Over the same time period, 192 patients initiated RRT
via the MPC (with at least 180 days nephrology followup). The initial RRT modality is shown in Figure 1.
Only 98 of these patients starting RRT via the MPC
after 1 December 2006 were included in the statistical
analyses to ensure that all comparisons to the suboptimal
starts seen by the RTN were made using contemporaneous populations.
Comparison of suboptimal HD starts seen by the RTN to
those who were not
In our HD unit, 42% of patients starting HD were suboptimal starts in the time period between the establishment of
the RTN position and study end (1 December 2006–31
December 2008). Thirty-six of 78 (46.2%) suboptimal
HD starts were seen by the RTN. Patients were similar in
RRT starts 1 Jan 05-31 Dec 08
n = 501
RRT starts via MPC
(Nephrology follow-up ≥180 days)
n = 192
RRT starts
1 Jan 05-30 Nov 06
n = 94
Suboptimal HD starts
(Nephrology follow-up <180 days)
n = 309
RRT starts *
1 Dec 06-31 Dec 08
n = 98
Patients on RRT 180 days after
HD start *
n = 78
- Recovered (n = 139)
- Died (n = 57)
- Withdrew (n = 16)
- Transferred / lost
(n = 19 )
Initial modality
HD
n = 66
Patients not on RRT
180 after HD start
n = 231
HD
n = 59
Independent RRT
n = 28
- PD (n = 16)
- HHD (n = 1)
- LD transplant (n = 11)
Independent RRT
n = 39
Not seen by RTN *
n = 42
- PD (n = 26)
- HHD (n = 3)
- LD transplant (n = 10 )
HD
n = 36
Independent RRT
n=6
- PD (n = 3)
- HHD (n = 1)
- LD transplant (n = 2 )
Seen by RTN *
After 1 Dec 06
n = 36
Modality 180 days after HD start
HD
n = 26
Independent RRT
n = 10
- PD (n = 7)
- HHD (n = 1)
- LD transplant (n = 2 )
Fig. 1. Patients starting RRT from 1 January 2005 to 31 December 2008. Abbreviations as follows: RRT, renal replacement therapy; MPC,
multidisciplinary predialysis clinic; RTN, renal triage nurse; HD, haemodialysis; PD, peritoneal dialysis; LD transplant, living donor transplant.
*Refers to the patient groups used for modality comparison in the study.
Transition of suboptimal HD starts to independent RRT
2305
Table 1. Comparison of baseline characteristics of suboptimal HD starts seen by the RTN to those not seen by the RTN
Characteristic
Male—no. (%)
Race—no. (%)
Asian
White
Other
Age—year
Lived alone—no. (%)
Yes
No
Unknown
Employment—no. (%)
Employed
Retired/disability
Unemployed
Unknown
Renal disease—no. (%)
Diabetes
Glomerulonephritis
Vascular disease
Other
Diabetes—no. (%)
Cerebrovascular disease—no. (%)
Estimated GFRa at HD start—mL/min/1.73 m2
Albumin—g/L
Haemoglobin—g/L
Intact PTH—pmol/L
Phosphate—mmol/L
Seen by RTN
n = 36
Not seen by RTN
n = 42
23 (63.9)
26 (61.9)
11 (30.6)
20 (55.6)
5 (13.9)
58.0 (19.0)
7 (16.7)
22 (52.4)
13 (31.0)
60.2 (16.7)
12 (33.3)
22 (61.1)
2 (5.6)
4 (10.8)
33 (89.2)
5 (11.9)
9 (25.7)
20 (57.1)
6 (17.1)
1 (2.8)
7 (18.4)
25 (65.8)
6 (15.8)
4 (9.5)
8 (22.2)
8 (22.2)
6 (16.7)
14 (38.9)
16 (44.4)
9 (25.0)
8.0 (4.3)
n = 33
28.3 (5.8)
n = 32
92.0 (12.0)
n = 33
31.9 (19.5)
n = 18
1.7 (0.6)
n = 23
8 (19.0)
8 (19.0)
7 (16.7)
19 (45.2)
15 (35.7)
3 (7.1)
7.9 (2.9)
n = 41
30.2 (5.8)
n = 35
93.1 (18.2)
n = 40
39.9 (36.2)
n = 27
1.7 (0.6)
n = 35
P-value
0.86
0.59
0.58
0.02
0.71
0.95
0.43
0.03
0.87
0.11
0.94
0.34
0.93
Continuous variables are expressed as mean (standard deviation).
a
Estimated glomerular filtration rate (GFR) was calculated using the four-variable MDRD equation [35].
both groups with respect to baseline characteristics; however, those seen by the RTNs were more likely to live alone
(33.3% versus 10.8%, P = 0.02) and to have comorbid
cerebrovascular disease (25.0% versus 7.1%, P = 0.03)
(Table 1).
The RTN spent a median education time of 5.6 h (IQR
1.5–9.2 h) over a median of 8 visits (IQR 3–8 visits) per
patient. At 180 days from HD start, 10 of 36 (27.8%) suboptimal HD starts in the RTN group switched to an independent RRT modality as follows: 7 switched to PD, 1
switched to HHD and 2 received a live donor kidney transplant. Only 6 of 42 (14.3%) suboptimal HD starts not seen
by the RTN switched RRT modality as follows: 3 switched
to PD, 1 switched to HHD and 2 received a live donor kidney transplant. Although this difference was of borderline
statistical significance (P = 0.08), logistic regression analysis adjusting for the variables living alone and comorbid
cerebrovascular disease demonstrated that patients seen by
the RTN were significantly more likely to be on an independent RRT modality at 180 days than those not seen
(OR = 3.75, 95% CI 1.08–13.05) (Table 2). There was also
a trend toward an association between living alone and a
lower likelihood of transitioning to an independent RRT
modality (OR 0.14, 95% CI 0.02–1.24; P = 0.18); how-
ever, this did not reach statistical significance, possibly
due to the relatively small sample size.
In univariate analysis, albumin level reached the threshold for inclusion in the multivariable model (P = 0.17). The
logistic regression model including serum albumin gave
similar results to the one adjusting only for the variables
living alone and cerebrovascular disease. Furthermore, in
the multivariable analysis, albumin level was not significantly associated with the outcome of interest (OR 1.14,
95% CI 0.98–1.32). Since 11 patients were missing serum
albumin values, we presented the model without serum albumin in Table 2 so that all the patients were included.
Of the 11 suboptimal HD starts who began dialysis after
the RTN position was established but were not been seen
Table 2. Multivariable logistic regression analysis of factors predicting
switch to independent RRT modalities in suboptimal HD starts at
6 months after dialysis initiation
Variable
Odds ratio
95% Confidence limits
P-value
Seen by RTN
Lived alone
Cerebrovascular disease
3.75
0.14
0.60
1.08–13.05
0.02–1.24
0.10–3.67
0.04
0.18
0.58
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J. Hanko et al.
Table 3. Comparison of baseline characteristics of suboptimal HD starts seen by the RTN to patients initiating RRT via the multidisciplinary
predialysis clinic
Characteristic
Male—no. (%)
Race—no. (%)
Asian
White
Other
Age—year
Renal disease—no. (%)
Diabetes
Glomerulonephritis
Other
Diabetes—no. (%)
Estimated GFR at RRT start—mL/min/1.73 m2
Albumin—g/L
Haemoglobin—g/L
Intact PTH—pmol/L
Phosphate—mmol/L
RTN patients
n = 36
MPC patients
n = 98
23 (63.9)
50 (51)
11 (30.6)
20 (55.6)
5 (13.9)
63.0 (16.8)
45 (45.9)
37 (37.8)
16 (16.3)
58.0 (19.0)
8 (22.2)
8 (22.2)
20 (55.6)
16 (44.4)
8.0 (4.3)
n = 33
28.3 (5.8)
n = 32
92.0 (12.0)
n = 33
31.9 (19.5)
n = 18
1.7 (0.6)
n = 23
27 (27.6)
24 (24.5)
47 (48.0)
42 (43.3)
10.5 (3.3)
n = 95
37.5 (5.3)
n = 95
112.3 (13.7)
n = 96
27.7 (19.9)
n = 88
1.8 (0.5)
n = 95
P-value
0.18
0.17
0.16
0.73
0.99
0.36
<0.001
<0.001
0.39
0.70
Continuous variables are expressed as mean (standard deviation).
by the RTN due to staffing difficulties, 2 recovered renal
function after being on dialysis for more than 180 days, 1
received a live donor kidney transplant and 1 switched to
PD. Exclusion of these patients from the analyses did not
substantively affect our results.
Comparison of patients followed in the MPC to suboptimal
HD starts seen by the RTN
Baseline characteristics of suboptimal HD starts seen by
the RTN were compared to patients starting any modality
of RRT via the MPC. Suboptimal HD starts were more
likely to be of white race (P = 0.01 for white versus any
other race) and to have lower haemoglobin (92 versus
112 g/L, P < 0.001) and serum albumin levels (28.3 versus
37.5 g/L, P < 0.001) at RRT start. There were no significant differences in sex, age, presence of diabetes, primary
renal disease or other laboratory variables (Table 3).
Of the 98 patients followed at the MPC for at least
180 days prior to RRT start, 59 patients (60%) started on
Table 4. Multivariable logistic regression analysis of factors associated
with independent RRT modalities
Variable
Odds ratio
95% Confidence
limits
P-value
RTN (versus MPC)
Age (per year increase)
Male
Race
Asian vs white
Other vs white
Haemoglobin
(per g/L increase)
Albumin
(per g/L increase)
0.74
0.95
0.92
0.19–2.94
0.92–0.97
0.40–2.12
0.67
<0.0001
0.84
0.90
0.27
0.99
0.38–2.24
0.03–2.48
0.96–1.03
0.4
0.26
0.87
1.10
1.01–1.20
0.03
hospital-based HD, 26 (27%) on PD, 3 (3%) on HHD and
10 (10%) received a pre-emptive live donor kidney transplant. Thus, a total of 39.8% started RRT on an independent modality compared to the independent RRT modality
rate of 27.8% achieved by the RTN (P = 0.20). Logistic
regression analysis adjusting for age, sex, race, serum albumin and haemoglobin levels confirmed no statistical difference in the rates of independent RRT modality achieved
by the RTN (assessed at 6 months after HD start) and those
achieved by the MPC (assessed at RRT start) (OR 0.74,
95% CI 0.19–2.94) (Table 4). In this model, higher serum
albumin levels were predictive of an increased likelihood
(OR 1.10, 95% CI 1.01–1.20), and advancing age was predictive of a decreased likelihood (OR 0.95, 95% CI 0.92–
0.97) of achieving an independent RRT modality.
Discussion
Suboptimal HD starts were common in our HD unit, accounting for 42% of incident HD patients during the time
period from establishment of the RTN position to study
end. This large group of patients is neglected in current
models of care. We addressed this lack of focus in our hospital-based HD unit by creating the RTN position, as an
addition to the dialysis care team, to provide a systematic
approach to the education of suboptimal HD starts with the
hypothesis that informed decision-making would improve
transition to independent modalities of RRT. The commitment required from the RTN to complete the education
process was significant at almost 6 h over eight visits
per patient; however, the time spent was rewarded by an
improvement in transition to independent modalities of
care: patients educated by the RTN were 3.75 times more
likely to switch to PD, HHD or live donor kidney trans-
Transition of suboptimal HD starts to independent RRT
plant than those not seen. The rate of independent RRT
modality switch in patients educated by the RTN was
not statistically different from the rate of independent
RRT achieved in patients educated in the MPC for at
least 6 months prior to RRT initiation. Multivariable analyses adjusting for potential confounders confirmed our
findings.
In this study, the suboptimal HD starts educated by the
RTN were more likely to live alone and to have comorbid
cerebrovascular disease than those not seen by the RTN.
Both of these factors may negatively impact a patient’s
ability to manage independent modalities and, therefore,
could influence modality selection. Those who live alone
will not have the social support to help them manage PD or
HHD, and those with a history of cerebrovascular disease
may have residual physical or cognitive impairment limiting their ability to perform independent dialysis. Although
neither of these factors reached statistical significance in
the multivariable model, it is possible that they may have
with a larger sample size.
Suboptimal HD starts are increasingly recognized as a
major challenge in renal care. They account for 15–60%
of all HD starts depending on the centre and on the definition
of suboptimal initiation [2–5]. This is consistent with the
42% of patients observed in our study. These patients have
a 2-fold increase in mortality, increased hospitalization,
suboptimal laboratory parameters and poorer quality of life
[28–32]. In addition, the cost of an admission for unplanned
HD start is estimated at $16,740 (Canadian dollars) versus
$3485 for an admission for planned HD start [5,33]. Suboptimal HD starts are likely to be a ‘sicker’ group of
patients, as suggested by our finding that they had significantly lower serum haemoglobin and albumin levels than
those starting RRT via the MPC, which may partly account
for their poorer outcomes. However, other factors are likely
to play a role in the poorer outcomes of these patients, such
as the duration of HD via a CVC. In view of this, we believe
that the improved transition to independent RRT modalities
facilitated by the RTN will translate into improved health
outcomes for patients and significant cost savings for health
care systems.
Considering PD specifically, education by the RTN resulted in 19% of suboptimal HD starts switching to PD
compared to 7% of those who were not educated by the
RTN. In a study of 3014 incident RRT patients in New Jersey, 35% of whom were referred within 90 days of RRT
start, 11.9% of those who started on HD subsequently
switched to PD [2]. Recent data from the United Kingdom
Renal Registry showed that, in those who started dialysis in
2005 with <90 days nephrology follow-up, 13.2% started
PD as their initial modality, and at 90 days following dialysis initiation, 22.1% were on PD [4]. Both of these studies
show that it is possible to transition patients from HD to PD
within different health care systems; however, neither study
outlined how transition was facilitated or how it might be
improved.
One other example of a similar model of care for suboptimal HD starts is reported in the literature. In Toronto,
following creation of a similar position to our RTN in
2005, suboptimal HD start patients choosing a home dia-
2307
lysis modality increased from 13 to 67% [34]. This is a
higher proportion than the 28% who switched in our study.
In the Toronto study, a nurse provided education for 233
individuals of whom only 119 remained within the health
region and had full follow-up information available. Of the
119 patients, 39 (33%) remained on in-centre HD, 51
(43%) switched to PD and 29 (24%) switched to HHD.
Since HHD patients from other regions were trained and
followed in Toronto, the independent modalities were likely overrepresented among the 119 patients. Taking into account all patients educated, 34% (80 of 233) switched to an
independent modality [or 44% if those who recovered
renal function or died (n = 52) are excluded]. As the author
noted, there were several extrinsic factors influencing patients’ modality choice such as lack of community dialysis
capacity and travel distance. These factors are likely to
vary, even between centres in the same country, and may
partly explain the difference in the rates of independent
RRT achieved between their study and ours. Regardless,
the education of suboptimal HD starts by a dedicated nurse
improved transition to independent modalities of RRT in
both Toronto and Vancouver.
The results of our study must be interpreted within the
context of the study design. Although data collection was
rigorous, the study was retrospective, observational, small
in size and from a single centre. In addition, we compared
data from sequential time periods and thus it is possible that
the effects attributed to the institution of the RTN position
may have occurred naturally with changes in clinical practice over time. However, this seems unlikely to account for a
substantial effect as a weekly team meeting was established
and essentially unchanged since 1997. Despite these limitations, we feel that our results are valid and applicable to
hospital-based HD programmes elsewhere.
Conclusion
In this study, an RTN dedicated to the education of suboptimal HD starts, who survived more than 180 days, increased
the likelihood of switching to an independent modality of
RRT. The rate of independent RRT achieved by the RTN
was comparable to the rate in those patients starting dialysis with a minimum 6-month education at an MPC. This
standardized approach to the care of suboptimal HD starts
should be considered in HD units where such patients are
common. We hypothesize that improved health outcomes
and potential cost savings may be realized.
Acknowledgements. We wish to thank the British Columbia Provincial
Renal Agency for its financial support of the RTN position and Cecilia
Li (Patient Services Manager) for assistance with implementation of the
RTN position.
Conflict of interest statement. None declared.
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Received for publication: 27.7.10; Accepted in revised form: 7.10.10