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Caring For the Person on Home Dialysis. IN: Elements of Excellence: A Team Approach to Chronic Kidney Disease Care. New York, NY: National Kidney Foundation. 2008. pp 91-100.

This chapter about caring for the person on home dialysis is from a manual that was developed to support the distinctive specialty practice for chronic kidney disease (CKD) from a multidisciplinary perspective. Clinicians on the CKD team—including nurses, dietitians, dialysis technicians, and social workers—can use this resource as a foundation for education, orientation, and specialty training. This chapter is from the second section of the manual that focuses on practical, clinical applications of the concepts of care outlined in the first half of the manual. Care of the person who chooses home dialysis involves collaboration among the patient and family, primary teams for either peritoneal or hemodialysis, and adjunct teams, including pretransplant team, vascular access team, and, when needed, the palliative care team. The chapter begins with the essential aspects of care and the ideal patient outcomes to be achieved by each patient-centered team. The chapter goes on to discuss collaboration between teams, and the members and roles of the primary team, and of adjunct teams. Most of the information in the chapter is presented in bulleted lists. 9 references.

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Environmental Aspects of Infection Control in the Dialysis Clinic. Nephrology News & Issues. 22(3): 36-41. March 2008.

This article is the second in a three-part series that focuses on how dialysis clinics can improve their management of infectious disease. The author reviews the environmental aspects of infection control in the dialysis clinic. The author notes that the hemodialysis setting presents environmental challenges due to a variety of possible sources of contamination: water, dialysate, frequently touched surfaces, intrinsically contaminated products such as saline and antimicrobial soaps, and extrinsically contaminated products such as multidose vials, refillable soaps, and flushes. In addition, there are multiple patients and staff members following multiple shifts that make standard infection control strategies difficult to maintain. In each area of concern, the author offers specific suggestions for infection control, including the restriction of the use of common supplies, instruments, medication, and trays and carts, as well as proper cleaning and disinfection of surfaces and equipment. The author concludes that the key to preventing infection is adherence to infection control strategies, accomplished by patient and staff education, knowledge, surveillance, and compliance. 4 references.

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Home Hemodialysis in This Millennium: The Return of the King?. Nephrology News & Issues. 22(2): 41-43. February 2008.

In this commentary, the author explains his support of home hemodialysis (HD) as a vital option for patients who need renal replacement therapy. The author notes that, to increase dialysis dose in a practical manner, there need to be radical changes in how or where dialysis is provided. The vast majority of patients still receive in-center HD three times per week, and a decreasing number of patients do peritoneal dialysis (PD) at home. The author stresses that by removing the schedule limitations of traditional dialysis, therapy can be more like the naturally functioning kidney, improving patient well-being and quality of life. The author reviews the changes over the years in the numbers of patients using home dialysis; summarizes the advantages of more frequent dialysis, including blood pressure control, volume control, phosphorus management, quality of life, reduced hospitalization, and increased survival; and briefly considers the issues that need to be addressed before home hemodialysis can truly experience a resurgence, including increased simplicity and patient support, physician awareness, and reimbursement. 1 figure. 1 table. 6 references.

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Home Hemodialysis. Bethesda, MD: National Kidney and Urologic Diseases Information Clearinghouse. 2008. 6 p.

A small but growing number of clinics offer home hemodialysis (HD) in addition to standard, in-clinic hemodialysis. Patients learn to treat themselves at the clinic, working with a dialysis nurse. Training can include a helper and often takes 3 to 8 weeks. Patients return to the clinic once a month to see the nephrologist, dialysis nurse, and dietitian. This fact sheet helps readers understand the option of home hemodialysis as a treatment for kidney failure. Topics include the usual schedule of in-clinic HD, how home HD works, the risks of complications with home HD, the advantages of home HD including flexible schedules, and some barriers to home HD. New, smaller dialysis machines are making HD more practical. People choosing home HD can choose between shorter daily treatments or longer nightly treatments. The fact sheet describes some of the research studies and programs currently underway in this area, including the End-stage Renal Disease program; the Frequent Hemodialysis Network (FHN); the U.S. Renal Data System (USRDS); and the Hemodialysis Vascular Access Clinical Trials Consortium. The fact sheet describes the availability of a patient education series titled the NIDDK Kidney Failure Series. The brochure concludes with the contact information for the National Kidney Foundation (www.kidney.org), the American Association of Kidney Patients (www.aakp.org), Home Dialysis Central (www.homedialysis.org), and a brief description of the activities of the National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC), a service of the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). 3 figures.

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Importance of Home Visits in Peritoneal Dialysis. Dialysis and Transplantation. 37(4): 132-136. April 2008.

This article reports on a study that assessed the training provided by a dialysis unit to patients who are performing peritoneal dialysis (PD) self-treatment at home. The study included 32 patients––13 women, 19 men; mean age 44.3 years, plus or minus 15.3 years––who answered a training assessment form comprising 31 questions during home visits. The patients’ average number of correct answers was 81 percent. Questions related to feeding, constipation, changing room, peritonitis, infections, medication, and material were those most often incorrectly answered. Infection is one of the primary reasons that patients must return to in-center dialysis or switch to hemodialysis; infectious complications are responsible for up to 6 percent of patient deaths. The authors conclude that lack of information about food to be avoided points to the importance of including a dietitian on the patient care team. Patients focused only on peritonitis as the infectious complication to watch; they had incomplete knowledge about the symptoms of and how to prevent place-of-exit and tunnel infections. The authors stress that patient training, in the home, should be repeated and tested at predetermined intervals. A chart reprints the training evaluation form used in the study. 1 table. 12 references.

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Infections in Dialysis Patients. Nephrology News & Issues. 22(2):48-59. February 2008.

This article reviews the problem of infections in dialysis patients, focusing on the causes of these infections and strategies to counter their negative effects. The authors remind readers that maintenance dialysis patients are at increased risk for infection due to well-defined immune deficits that are caused by the uremic state. These immune deficits in turn lead to increased rates of bacterial infections, particularly bloodstream infections and pneumonia. The authors discuss bloodborne pathogens of particular concern to patients on hemodialysis, notably hepatitis B, hepatitis C, and hepatitis D; HIV and AIDS; bacterial and fungal infections, particularly methicillin-resistant Staphylococcus aureus (MRSA); vascular access-related infections; and infections associated with water, dialysate, reuse, and dialysis machines. For each, the authors review transmission, host susceptibility, prevention, and infection control strategies. The article concludes with a list of 12 specific strategies that all dialysis facilities should consider implementing: vaccinate staff and patients; use catheters only when necessary, prefer fistulas or grafts; optimize access care; target the pathogen; access the experts; use local data; be wary of vancomycin use; treat infection, not contamination or colonization; stop antimicrobial therapy as soon as possible; follow infection control precautions; practice hand hygiene; and incorporate patients into access care and infection control measures. 21 references.

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Pregnancy and Successful Full-Term Delivery in a Patient on Peritoneal Dialysis: One Center’s Experience and Review of the Literature. Dialysis and Transplantation. 36(8):438-444. August 2007.

This article presents the case of pregnancy and successful full-term delivery of a 32-year-old woman on peritoneal dialysis due to chronic tubulointerstitial nephritis secondary to vesicoureteral reflux. The patient already had a functioning arteriovenous fistula (AVF), which was created before she was started on continuous ambulatory peritoneal dialysis (CAPD). The patient’s pregnancy was discovered when she was 10 weeks pregnant; the patient, her partner, and physicians agreed that the pregnancy would continue with the patient on CAPD for as long as possible under close supervision and would change to hemodialysis (HD) if the need arose. The authors describe the patient’s care throughout the pregnancy, including the monitoring while hospitalized in the nephrology ward from the 28th week to the end of her pregnancy. Topics include the patient’s weight changes, erythropoietin requirements, medications, delivery, postdelivery management, and care of the newborn. The authors conclude with a discussion of this case and a review of the related literature. They stress that this article was not written to encourage patients with end-stage renal disease (ESRD) to become pregnant, which is still a risky undertaking; rather, to emphasize that if the parents very strongly desire a child or if the pregnancy is accidental but the patient wants to continue to term, a pregnancy can be managed effectively. 4 figures. 45 references.

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Prevention of Sudden Cardiac Death in Dialysis Patients: A Nephrologist’s Perspective. Dialysis and Transplantation. 37(4): 124-129. April 2008.

This article presents the nephrologist’s perspective on the prevention of sudden cardiac death in dialysis patients, an unfortunately common event in the dialysis population. The author stresses that prevention of sudden death can be accomplished in this group by proper management of cardiac disease and attention to dialysis treatment. The proper usage of medications such as ACE inhibitors and beta blockers is likely to decrease the risk of sudden death, yet these medications are underused in the dialysis population. The author discusses dialysis treatment as a cardiac stress, the appropriate management of dialysate potassium, and volume shifts occurring during dialysis. The author calls for the development in each dialysis center of a systematic method to identify risk factors for sudden death, institute appropriate treatment, and monitor outcomes. Most of the systems currently in place concentrate on the dialysis procedure, with most time in dialysis rounds covering dialysis adequacy, calcium phosphate metabolism, anemia, and adjustment of dry weight. The evaluation of cardiac risk factors must be incorporated into this system of patient care. 29 references.

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Renal Resource and Buyers Guide 2008. Nephrology News & Issues. 22(5): 4-62. 2008.

This special issue of Nephrology News & Issues offers the annual renal resources and buyers’ guide, a comprehensive directory of products and services available for the renal care community. The guide has two sections: a products-and-services listing, arranged alphabetically by category, with company contact information provided; and the company directory, an alphabetical listing of the companies included. The company directory lists the name and address of the company, its website address, and a brief description of the products or services offered. The products-and-services categories include blood analysis devices, blood lines, blood pressure monitors, business support services, CAPD equipment, catheters, CCPD equipment, chairs, clothing, concentrate, dialysis machines, dialyzers, diet and nutrition, disinfectants, dry mouth products, equipment maintenance and repair, facility planning, fistula needles, hemodialysis supplies, hemofiltration supplies, heparin, home hemodialysis, immunosuppressives, implantable infusion devices, insulin, medical waste disposal, monitoring devices, needlestick protection, patient education, office supplies, peritoneal dialysis, pharmaceuticals, plasmapheresis, rehabilitation and exercise, reprocessing, scales, shunts, software, training, sterilants, syringes, ultrasound, vascular access, and water testing and treatment. The guide includes a list of nephrology conferences for 2007, a handy list of websites for renal associations, and an information page on how to use the journal’s website, www.nephronline.com.

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Starting Dialysis: What You Need to Know. Kidney Beginnings. 7(6): 10-14. May 2008.

This article reviews the basic information that patients just beginning dialysis need to know. The author reviews the five stages of chronic kidney disease (CKD), which are based on a common measure of kidney function called the estimated glomerular filtration rate (GFR). The article advises patients with stage 4 CKD to meet regularly with a nephrologist and health care team for monitoring and treatment of complications of CKD, such as anemia, bone disease, malnutrition, acidosis, and decreased sense of well-being; patients at this stage must follow diet, medications, blood pressure control, and lifestyle recommendations. The article lists and describes the types of kidney replacement therapy available for patients with stage 5 CKD, including home or in-center hemodialysis, peritoneal dialysis, kidney transplantation, or choosing nontreatment. Other topics include the time needed for each type of kidney replacement therapy, the different types of vascular access used for hemodialysis, the types of peritoneal dialysis (PD), preparation for PD, and understanding the option of declining dialysis. Charts summarize the advantages and disadvantages of each type of kidney replacement therapy. The article concludes with a brief description of some additional instructional materials available from the American Association of Kidney Patients (AAKP) website (www.aakp.org). 4 figures. 4 tables. 5 references.

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