Patient-centered care: facilitating home dialysis and improving health-related quality of life

The number of patients with chronic kidney disease and end stage kidney disease, i.e. kidney failure, is continuing to rise globally. This is a major economic problem, as dialysis (kidney replacement therapy), is an expensive treatment. Dialysis can be performed both at the dialysis centre and at home. Worldwide, home dialysis is utilized significantly less often than in-centre haemodialysis (CHD) with few exceptions. This is remarkable, as home dialysis - both peritoneal dialysis and home haemodialysis - is associated with similar survival as CHD and with more independence and greater scheduling flexibility than CHD. Home dialysis might also be less expensive. Therefore, this thesis focused on outcomes of home dialysis. We demonstrated that the current home dialysis population is ageing due to both an increase in kidney transplantation in younger patients and an increase in the absolute number of elderly patients. Both age and comorbidity are frequently reported barriers to home dialysis; in this thesis we suggest that these determinants may be mistakenly perceived as barriers. In our study, comorbidity was not associated with dialysis choice if corrected for BMI and age. More pre-dialysis patients might thus be eligible to receive home dialysis. In addition, a home visit prior to initiating dialysis treatment helps to identify patients with suitable housing for home dialysis. Patients on peritoneal dialysis are admitted more frequently to the hospital than CHD patients. This probably results from a higher threshold to admit a CHD patient, who is frequently seen in the dialysis ward during the week. PD patients are most often admitted for peritonitis. Infections are also an important reason for discontinuation of PD (technique failure). In this thesis modifiable causes for PD technique failure were explored, in order to increase the treatment longevity. Important causes were infections, fluid leakage and PD catheter problems. Progress in technology notwithstanding, traditionally important outcomes are disappointing in dialysis patients: survival is low, hospital admissions are frequent and the technique failure rate is high. Health-related quality of life (HRQoL) is becoming an increasingly important outcome in patients with kidney failure, who consider HRQoL a core outcome alongside more traditional outcomes. In this thesis we studied HRQoL during the major COVID-19 pandemic and in a specific patient group, those treated with nocturnal haemodialysis. By performing a systematic review and meta-analysis of studies on HRQoL, we found marginally higher HRQoL scores for home dialysis patients across the world. The finding that the overall quality of included studies was poor and few longitudinal studies exist, form the rationale of the DOMESTICO study, of which this thesis includes the study protocol. The prospective DOMESTICO study will investigate the effect of home dialysis therapies on HRQoL, cost-effectiveness and clinical outcomes, compared to CHD in the current dialysis population

Patient-centered care: facilitating home dialysis and improving health-related quality of life

The number of patients with chronic kidney disease and end stage kidney disease, i.e. kidney failure, is continuing to rise globally. This is a major economic problem, as dialysis (kidney replacement therapy), is an expensive treatment. Dialysis can be performed both at the dialysis centre and at home. Worldwide, home dialysis is utilized significantly less often than in-centre haemodialysis (CHD) with few exceptions. This is remarkable, as home dialysis - both peritoneal dialysis and home haemodialysis - is associated with similar survival as CHD and with more independence and greater scheduling flexibility than CHD. Home dialysis might also be less expensive. Therefore, this thesis focused on outcomes of home dialysis. We demonstrated that the current home dialysis population is ageing due to both an increase in kidney transplantation in younger patients and an increase in the absolute number of elderly patients. Both age and comorbidity are frequently reported barriers to home dialysis; in this thesis we suggest that these determinants may be mistakenly perceived as barriers. In our study, comorbidity was not associated with dialysis choice if corrected for BMI and age. More pre-dialysis patients might thus be eligible to receive home dialysis. In addition, a home visit prior to initiating dialysis treatment helps to identify patients with suitable housing for home dialysis. Patients on peritoneal dialysis are admitted more frequently to the hospital than CHD patients. This probably results from a higher threshold to admit a CHD patient, who is frequently seen in the dialysis ward during the week. PD patients are most often admitted for peritonitis. Infections are also an important reason for discontinuation of PD (technique failure). In this thesis modifiable causes for PD technique failure were explored, in order to increase the treatment longevity. Important causes were infections, fluid leakage and PD catheter problems. Progress in technology notwithstanding, traditionally important outcomes are disappointing in dialysis patients: survival is low, hospital admissions are frequent and the technique failure rate is high. Health-related quality of life (HRQoL) is becoming an increasingly important outcome in patients with kidney failure, who consider HRQoL a core outcome alongside more traditional outcomes. In this thesis we studied HRQoL during the major COVID-19 pandemic and in a specific patient group, those treated with nocturnal haemodialysis. By performing a systematic review and meta-analysis of studies on HRQoL, we found marginally higher HRQoL scores for home dialysis patients across the world. The finding that the overall quality of included studies was poor and few longitudinal studies exist, form the rationale of the DOMESTICO study, of which this thesis includes the study protocol. The prospective DOMESTICO study will investigate the effect of home dialysis therapies on HRQoL, cost-effectiveness and clinical outcomes, compared to CHD in the current dialysis population