PD BUDDY: USING SMARTPHONE TECHNOLOGY TO IMPROVE PATIENT CARE.

M BUDD1, R ROGERS1 K SOON-TAN1, GHELLEN2, M VARNFIELD3

1Metro South Health Service District, Logan Hospital, Brisbane, Queensland; 2Metro South Health Service District, Transformation and Innovation Collaborative; 3The Australian e-Health Research Centre, Health and Biosecurity, CSIRO, Brisbane, Queensland

Aim: To develop and research the effectiveness of a peritoneal dialysis (PD) app (PD-By) and web portal for patients and clinicians. This smartphone app will allow patients to record vital information such as prescription, ultrafiltration, blood pressure and weight. This information will be automatically uploaded to the web-portal for clinician access. With more accurate records it is envisioned that we will see more efficient and effective patient clinics, improved peritonitis rates and will help patients better manage their health in their own environment.

Background: Online health tracking is a relatively new innovation used to empower patients. Currently PD patients in our unit document vital health information in a simple exercise book, which is often incomplete or forgotten when a patient attends a PD clinic appointment. PD-BUDDy is an innovation being developed locally in collaboration with CSIRO to create the platform for patients on PD and their clinicians.

Methods: Pilot trial underway for six months using the app to determine the ease and feasibility of a smartphone application. 38 patients with a mean age of 56 years have been identified as suitable, 27% of participants are on CAPD with 73% on APD. On Average patients spend 113 minutes at each clinic appointment. Primary endpoints are reduction in consultation time by one third without increase in complication rates. Secondary endpoints will be patient satisfaction evaluated through questionnaire responses.

Conclusions: Innovation and communication in health care are essential. PD-BUDDy will streamline the way patients record and store information and will provide better communication and management of PD patients, potentially leading to improved health outcomes and extending their adverse event free time on the home-based therapy.

ASEPTIC TECHNIQUE MAINTAINS STERILITY OF ANTIBIOTIC-LOADED PERITONEAL DIALYSIS FLUID

L HUANG1,2, E RAMAS1, P PRASAD3, J CATANIA4, P MEADE4, E BUTLER3, LP MCMAHON1,2

1Department of Renal Medicine, Eastern Health, Box Hill, Victoria; 2Department of Medicine, Eastern Health Clinical School, Box Hill, Victoria; 3Department of Pharmacy, Eastern Health, Box Hill, Victoria; 4Department of Pathology and Microbiology, Eastern Health, Box Hill, Victoria

Aim: To compare the sterility of antibiotic-loaded peritoneal dialysis fluid (PDF) admixed using sterile-technique versus non-touch aseptic technique (NTAT).

Background: There is a paucity of data on the sterility of PDF after drug admixture. ISPD guidelines suggest using sterile-technique when admixing IP antibiotics, however the degree of sterility remain unclear. This issue is most pertinent when preparing take-home PDF for the outpatient treatment of peritonitis.

Methods: Groups of n=8 PDF (1.5% Dianeal or Extraneal) were admixed with antibiotics (ceftazidime and vancomycin, 1g/L) or 20mL saline, either by a pharmacist using sterile-technique in a sterile-suite (sterile gloves, filtered air, laminar flow hood), or a nurse in a clinical room utilising NTAT. PDF inoculated with 1×106 CFU/L of Coagulase-negative Staphylococcus (CNS, S. epidermidis or S. haemolyticus) with or without antibiotics, served as positive controls. Admixed PDF were left in room temperature for 72-hours, before being cultured using the BacT/ALERT system. A positive culture by day-5 constitutes a contamination. Differences in proportion of contamination between groups were assessed by the Χ2 test.

Results: Eighty PDF-bags completed microbiological testing. PDF sterility was maintained in all bags, independent of technique (sterile-technique vs. NTAT), type of PDF (Dianeal vs. Extraneal), or whether antibiotics were admixed (antibiotics vs. saline). Of the positive controls, CNS inoculated bags without antibiotics were all culture positive (8/8 for both S. epidermidis and S. haemolyticus); however, when inoculated into antibiotic loaded-PDF, only S. haemolyticus remained culture-positive (Χ2,df=27.67, 3, p<0.0001).

Conclusions: PDF sterility can be maintained using non-touch aseptic technique, for up to 3-days at room temperature. Currently, there is insufficient evidence to utilise a sterile-suite when admixing take-home PDF.

OUTCOMES OF SUBCUTANEOUSLY BURIED PERITONEAL DIALYSIS CATHETERS BETWEEN 2006 AND 2014 AT ROYAL DARWIN HOSPITAL

T SOE1, W MAJONI1, 2, 3, JT HUGHES1, 2, K PRIYADARSHANA1, M SUNDARAM1, A ABEYARATNE1

1Department of Nephrology, Division of Medicine, Royal Darwin Hospital, NT; 2Menzies School of Health Research, Charles Darwin University, Darwin, NT; 3Northern Territory Clinical School, Flinders University, Darwin, NT

Aim: To determine whether subcutaneously buried peritoneal dialysis (SBPD) catheter offers safe and reliable dialysis access for patients with end stage kidney disease (ESKD).

Background: Peritoneal dialysis (PD) is an important treatment modality for ESKD, allowing home based care which is a critical need of many Indigenous patients in the Northern Territory.  Potential benefits of a pre-emptively placed SBPD catheter include facilitating timely dialysis initiation, decreased use of central venous catheter and reduced burden of PD catheter care at dialysis initiation.

Methods: We analysed all cases of SBPD catheters between 2006 and 2014 at Royal Darwin Hospital. The duration of catheter embedment, functionality of catheters at first use and complications at placement and exteriorization were described.

Results: SBPD catheters were inserted in 97 patients (48% male, mean age: 50 ±13years). Exteriorisation occurred in 62 patients (63%) at median 161 days (range: 33 to 2598) of embedment. Eighteen catheters (30%) had suboptimal flow. After surgical revision, fibrin removal and constipation management, 54 (87%) of exteriorised catheters achieved adequate function for dialysis. Thirty-five (36%) of total catheters were never exteriorised (pre-emptive transplant (n=2), modality change (n=22), surgical or catheter related complications (n=8) and death prior to starting dialysis (n=3)). Few insertion related complications (haematoma n=6, infection n=3, perforated bowel n=1, ileus n=1, peritoneal fluid leak n=1 and delayed wound healing n=1) were documented. After exteriorisation, exit site infection (n=5), peritonitis (n=1), traumatic exteriorisation (n=5), bleeding (n=2), perforated bowel (n=1) and damaged or short exteriorised portion of catheters (n=6) were recorded.

Conclusions: SBPD catheters were safe and achieved a favourable rate of optimal function (87%). Careful selection of patient is important to minimise futile catheter placement and complications.

VASCULAR ACCESS OUTCOMES REPORTED IN RANDOMISED TRIALS CONDUCTED IN PATIENTS REQUIRING HAEMODIALYSIS: A SYSTEMATIC REVIEW

AK VIECELLI1, E O’LONE2, B SAUTENET3, JC CRAIG2, A TONG2, E CHEMLA4, LS HOOI5, T LEE6, C LOK7, KR POLKINGHORNE8, RR QUINN9, T VACHHARAJANI10, R VANHOLDER11, L ZUO12, AB IRISH13, TA MORI13, EM PASCOE1, DW JOHNSON1, CM HAWLEY1

1School of Medicine, University of Queensland, Brisbane, Queensland; 2Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, New South Wales; 3University Francois Rabelais, Tours, France; 4St George’s University NHS Foundation Trust, London, United Kingdom; 5Department of Medicine and Haemodialysis Unit, Hospital Sultanah Aminah, Johor Bahru, Malaysia; 6Department of Medicine and Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama, United States; 7Department of Medicine, University of Toronto, Toronto, Ontario, Canada; 8School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria; 9Departments of Medicine & Community Health Sciences, University of Calgary, Calgary, Canada; 10Division of Nephrology, W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina, United States; 11Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; 12Peking University People’s Hospital, Beijing, China; 13School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia

Aim: To assess the scope and consistency of vascular access (VA) outcomes reported in haemodialysis trials.

Background: Many randomised controlled trials have been performed to improve VA outcomes. These trials can inform decision-making, provided the reported outcomes are relevant and measured consistently to allow interventions to be compared across trials.

Methods: All randomised controlled trials and trial protocols reporting any VA outcome in adult haemodialysis patients from January 2011 to June 2016 were identified from clinicaltrials.gov, Cochrane CENTRAL, Embase, and MEDLINE. The frequency and characteristics of VA outcomes were analysed and classified.

Results: From 168 relevant trials, 1426 access-related outcome measures were extracted and classified into 23 different outcomes. The three most commonly reported outcomes were function (136 [81%] trials), infection (63 [38%]), and maturation (31 [18%]). Function was measured in 489 different ways and at 46 different time points, but most frequently reported as “mean access blood flow (mL/min)” (37 [27%] trials) and “number of thromboses” (30 [22%]). Infection was assessed in 136 different ways with “number of access-related infections” being the most frequently used measure. Maturation was assessed in 44 different ways, at 15 different time points, and most commonly characterised by vein diameter and blood flow. Patient-reported outcomes, including pain (19 [11%]) and quality of life (5 [3%]), were reported infrequently. Only a minority of trials used previously standardised outcome definitions.

Conclusions: The reporting of access outcomes in haemodialysis trials is highly heterogeneous with limited patient-reported outcomes and infrequent use of standardised outcome measures. Efforts to standardise outcome reporting for VA are critical to optimising the comparability, reliability and value of trial evidence to improve outcomes for patients requiring haemodialysis.

REPORT OF THE STANDARDISED OUTCOMES IN NEPHROLOGY-HAEMODIALYSIS (SONG-HD) CONSENSUS WORKSHOP ON ESTABLISHING A CORE OUTCOME MEASURE FOR VASCULAR ACCESS IN HAEMODIALYSIS

AK Viecelli1, A Tong2, E O’Lone2, A Ju2, C Hanson2, B Sautenet3, JC Craig2, B Manns4, M Howell2, E Chemla5, LS Hooi6, DW Johnson1, T Lee7, C Lok8, KR Polkinghorne9, RR Quinn10, T Vachharajani11, R Vanholder12, L Zuo13, CM Hawley1 on behalf of THE SONG Investigators

1School of Medicine, University of Queensland, Brisbane, Queensland; 2Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, Sydney, New South Wales; 3University Francois Rabelais, Tours, France; 4Departments of Medicine and Community Health Sciences; Libin Cardiovascular Institute and O’Brien Institute of Public Health,  University of Calgary, Calgary, Alberta, Canada; 5St George’s University NHS Foundation Trust, London, United Kingdom; 6Department of Medicine and Haemodialysis Unit, Hospital Sultanah Aminah, Johor Bahru, Malaysia; 7Department of Medicine and Division of Nephrology, Veterans Affairs Medical Center, Birmingham, Alabama, United States; 8Department of Medicine, University of Toronto, Toronto, Ontario, Canada; 9Department of Medicine, Monash University, Melbourne, Victoria; 10Medicine and Community Health Sciences, University of Calgary, Calgary, Canada; 11Division of Nephrology, W.G. (Bill) Hefner Veterans Affairs Medical Center, Salisbury, North Carolina, United States; 12Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium; 13Peking University People’s Hospital, Beijing, China

Aim: To identify and describe the preferred core outcome measure for vascular access (VA), and the rationale for its selection, in the context of an international consensus workshop.

Background: Vascular access is a critical outcome domain for all stakeholders in the setting of haemodialysis that is infrequently and inconsistently reported in trials.

Methods: In total, 13 patients/caregivers and 46 health professionals from 12 countries attended. In facilitated breakout groups, participants discussed the development and implementation of a VA core outcome measure. The transcripts were analysed thematically.

Results: Five themes were identified. Participants reiterated the broad relevance of function given its applicability to all VA types, its impacts on quality of life, survival and various access-related outcomes, and the degree of multidisciplinary involvement required to achieve a functioning access. Experiential relevance and severity were identified as drivers for prioritisation of other outcomes, such as aneurysms (patients) or steal syndrome (clinicians). A core outcome measure required absolute feasibility for implementation across different clinical and trial settings and participants advocated for a simple, practical and flexible outcome measure with a pragmatic and operational definition. Integrating patients’ values and preferences was warranted to enhance the relevance of the measure. Ensuring validity and reliability was exemplified in proposed outcome measures for function including “uninterrupted use of the access without the need for interventions” or “ability to receive prescribed dialysis”, while “access blood flow” was deemed too expensive and unreliable.

Conclusions: Patients, caregivers and health professionals identified VA function as the core outcome for inclusion in haemodialysis trials, which should be assessed using a pragmatic, patient-centred, and reliable outcome measure.

REPEATED SUBCLINICAL BLOOD-PRESSURE VOLATILITY DEMONSTRATED BY CONTINUOUS MONITORING DURING CONVENTIONAL OUTPATIENT HAEMODIALYSIS

J EVANS2, R WALKER1,2, S WILSON1,2,3

1ALFRED HEALTH, Melbourne, Victoria; 2Monash University, Melbourne, Victoria; 3BAKER IDI, Melbourne, Victoria

Aim: To characterise intradialytic systolic blood pressure (SBP) changes across individual and sequential outpatient haemodialysis (HD) treatments.

Methods: Continuous beat-to-beat SBP monitored using SOMNOtouchTM NIBP in parallel to routine therapy in 17 stable HD outpatients (76% male, 41% diabetic, 17% vascular catheter, mean age 64 years (range 23-83 years), mean (+SD) dialysis vintage 59+48 months. 7 patients underwent sequential monitoring across 1 week of treatment. Following noise reduction by median-hybrid filter, the SBP signal was analysed by summative intradialytic range, start and end-HD SBP and overall variability. Sequential HD sessions were assessed intra-individually by repeated ANOVA and paired-matrix Kolmogorov-Smirnov distribution analyses.

Results: There were no symptomatic SBP events observed. On aggregate there was a net upward SBP trajectory 4+11mmHg from start-HD SBP to end-HD SBP with a large, asymptomatic intraHD-SBP peak-to-trough gap of 26+17mmHg (range 9-86mmHg). The greatest net SBP changes were associated with ACE inhibitor prescription (p<0.05). SBP variability as measured by standard deviation was positively associated with the presence of diabetes (p<0.05). Age was the strongest predictor of intradialytic SBP range (r2=0.6, p<0.05). Across serial HD each patient showed significant differences in SBP distribution patterns (p<0.001). Intraindividual mean (IQR) dispersal across start, end and intraHD-mean SBP was 12 (6-18mmHg), 12 (5-16mmHg) and 14 (9-18mmHg) respectively. There was no common pattern of summative or time-point SBP reduction over the course of 1 week.

Conclusions: Substantial asymptomatic SBP volatility is common during HD when characterised using continuous monitoring techniques and the pattern of SBP behaviour is inconsistent from one treatment to the next. These observations raise doubt about the usefulness of intermittent conventional recordings of SBP, particularly in guiding the personalisation of HD prescription.

IDENTIFYING THE CRITICAL DIMENSIONS OF FATIGUE FOR A CORE OUTCOME MEASURE FOR TRIALS IN HAEMODIALYSIS: AN INTERNATIONAL SURVEY

A JU1,2, M HOWELL1,2, M UNRUH3, SV JASSAL4, G OBRADOR5, S DAVISON6, J DAPUETO7, MA DEW8, R FLUCK9, M GERMAIN10, D O’DONOGHUE11, JI SHEN12, E O’LONE1,2, JC CRAIG1,2, A TONG1,2 FOR THE SONG-HD INITIATIVE

1Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia; 2Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW, Australia; 3Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, NM, USA; 4Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada; 5Universidad Panamericana School of Medicine, Mexico City, Mexico; 6Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; 7Departamento de Psicología Médica. Hospital de Clínicas. Facultad de Medicina. Universidad de la República. Montevideo, Uruguay; 8Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; 9Department of Renal Medicine, Royal Derby Hospital, Derby, United Kingdom; 10Renal and Transplant Associates of New England, Division of Nephrology, Baystate Medical Center, Tufts University School of Medicine, Boston, MA, USA; 11Department of Renal Medicine, Salford Royal Hospital, Salford, United Kingdom; 12Departmment of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

Aim: To identify the most critical dimensions for inclusion in a core outcome measure of fatigue in haemodialysis trials.

Background: Measures of fatigue used for research in patients on haemodialysis have differing dimensions, length, and scales. The extent to which of the dimensions of fatigue are valued by patients and health professionals are unknown.

Methods: An online survey was conducted among patients/caregivers and health professionals in English and Spanish. The survey consisted of 11 content dimensions of fatigue such as ‘life participation’ and ‘muscle weakness’, and 4 modes of assessment such as ‘severity’ and ‘frequency’, identified in existing measures. A 9-point Likert scale was used to assess absolute importance and relative importance obtained from a best-worst scale (BWS) task.

Results: In total, 342 (60%) health professionals and 227 (40%) patients/caregivers from 60 countries participated in the two surveys. Among all participants, the top rated dimension was ‘life participation’ (impact of fatigue on life participation) with a mean Likert score of 7.55 (95%CI: 7.42-7.68) for the English survey and 5.50 (95% CI: 4.90-6.10) for the Spanish survey. Severity was more important than frequency, duration or change in fatigue in both the English (7.20: 7.06-7.34) and Spanish survey (5.13: 4.52-5.74). English-speaking patients placed highest relative importance on ‘life participation’ (BWS score 9.0:7.8-10.4), compared with Spanish-speaking patients for whom ‘post-dialysis fatigue’ was most important (9.0:7.0-11.0).

Conclusions: Impact of fatigue on life participation was identified as a critical dimension of fatigue, and severity the most important metric. Differences in relative importance of fatigue dimensions suggest cultural differences in priorities. The core outcome measure for fatigue should include severity of impact upon life participation with consideration of cultural validity.

THE PERSPECTIVES OF HEALTHCARE PROVIDERS ON THE NUTRITIONAL MANAGEMENT OF PATIENTS ON HAEMODIALYSIS: AN INTERVIEW STUDY

J STEVENSON1,3, A TONG2,3, KL CAMPBELL5, JC CRAIG2,3, VW LEE1,3,4

1Westmead Clinical School, The University of Sydney, NSW; 2Sydney School of Public Health, The University of Sydney, Sydney, NSW; 3Centre for Kidney Research, The Children’s Hospital at Westmead, Sydney, NSW; 4Department of Renal Medicine, Westmead Hospital, Sydney, NSW; 5Faculty of Health Sciences and Medicine, Bond University, Robina, QLD

Aim: To describe the perspectives of healthcare providers on the nutritional management in patients on haemodialysis.

Background: Nutritional management in haemodialysis is complex, with patients requiring support to make and sustain appropriate dietary behaviours. Multidisciplinary teams play an important role in managing nutritional priorities, providing counselling, and developing patients’ self-management skills.

Methods: Semi-structured interviews were conducted with 42 renal health professionals (nephrologists, nephrology trainees, nurses and dietitians) from  21 haemodialysis centres in Australia. Transcripts were analysed thematically.

Results: We identified six major themes: responding to changing clinical status (individualising strategies to patient needs, prioritising acute events, adapting guidelines), integrating patient circumstances (assimilating life priorities, access and affordability), delineating specialty roles in collaborative structures (shared and cohesive care, pivotal role of dietary expertise, facilitating access to nutritional care, perpetuating conflicting advice and patient confusion, devaluing nutritional specialty), empowerment for behaviour change (enabling comprehension of complexities, building autonomy and ownership, developing self-efficacy through engagement, tailoring self-management strategies), initiating and sustaining motivation (encountering motivational hurdles, empathy for confronting life changes, fostering non-judgmental relationships, emphasising symptomatic and tangible benefits, harnessing support networks), and organisational and staffing barriers (staffing shortfalls, readdressing system inefficiencies).

Conclusions: Organisational support with collaborative multidisciplinary teams and individualised patient care were seen as necessary for developing positive patient-clinician relationships, delivering consistent nutrition advice, and building and sustaining patient motivation to enable dietary behaviour change. Improving service delivery and developing and delivering targeted, multi-faceted self-management interventions may enhance current nutritional management of patients on haemodialysis.

About ANZSN

The ASM is hosted by Australian and New Zealand Society of Nephrology.

The aims of the Society are to promote and support the study of the kidney and urinary tract in health and disease, and to ensure the highest professional standards for the practice of nephrology in Australia and New Zealand.

Conference Managers

Please contact the team at Conference Design with any questions regarding the Annual Scientific Meeting

© 2015 - 2016 Conference Design Pty Ltd