SummaryBackground and objectives The effect of in-hospital education on the adoption of home dialysis (peritoneal dialysis [PD] and home hemodialysis [HHD]) after an unplanned dialysis start is unknown.Design, setting, participants, & measurements Clinical demographics of consecutive patients acutely initiating hemodialysis (HD) from January 2005 to December 2009 were abstracted using institutional electronic records. All patients received multimedia chronic kidney disease education by the same advanced care nurse practitioner before discharge from the hospital. Clinical characteristics of patients choosing home dialysis or staying on in-center HD were compared. Results

As a result of the changing dialysis demographics, nephrologists are increasingly faced with problems traditionally considered to be geriatric issues. The specialty of nephrology has often been seen as using intensive, expensive, and complex technologies for patient care. Dialysis programs have evolved into highly efficient, fast-paced units that accommodate a rapid turnover of patients. They are in direct contrast to geriatric programs, which use geriatric principles to offer simple, multidimensional, holistic care to frail older patients. Finding the balance between nephrology and geriatric skill sets is a particular challenge for up-and-coming nephrologists who have an interest in geriatric nephrology. This mini-review addresses some of the challenges, increases awareness of specific issues, and highlights new opportunities in this field.

BackgroundThere is a paucity of information about the views of dialysis nurses towards dialysis modality selection, yet nurses often have the most direct contact time with patients. We conducted a survey to better understand nurses’ attitudes and perceptions, and hypothesized that nurses with different areas of expertise would have differences in opinions.MethodsWe administered an electronic survey to all dialysis/predialysis nurses (n = 129) at a large, tertiary care center. The survey included questions about preferred therapy - in-center hemodialysis (CHD), versus home dialysis (home hemodialysis and peritoneal dialysis) and ideal modality mix. Responses were compared between nurses with home dialysis and CHD experience.ResultsThe survey response rate was 69%. Both nursing groups ranked patient caregivers and dialysis nurses as having the least impact on patient modality selection. For most patient characteristics (including age > 70 years and presence of multiple chronic illnesses), CHD nurses felt that CHD was somewhat or strongly preferred, while home dialysis nurses preferred a home modality (p < 0.001 for all characteristics studied). Similar differences in responses were noted for patient/system factors such as patient survival, cost to patients and nursing job security. Compared to CHD nurses, a higher proportion of home dialysis nurses felt that CHD was over-utilized (85% versus 58%, p = 0.024).ConclusionDialysis nurses have prevailing views about modality selection that are strongly determined by their area of experience and expertise.

This article reports the pretransplant findings of the first phase of a three-phase, longitudinal study examining relationships among personality traits and self-care abilities and behaviors of Ontario adults pre- and post-renal transplant. A consortium of Ontario nurse researchers representing three of Ontario's five renal transplant centers conducted this research. All adults on the cadaver transplant lists of 15 Ontario dialysis centers were invited to participate. One hundred ninety-eight adults awaiting renal transplant were enrolled in the study, representing a 70% response rate. A cross-sectional, correlational design was used for the pretransplant phase. Self-report measures with known psychometric properties were used; validity and reliability of the measures were supported by the sample. Data were analyzed using descriptive approaches, correlational analyses, multiple regression, and path analysis. Relationships were supported among selected personality traits, health state and self-care abilities and behaviors. Further research to examine personality traits and health state in relation to adult self-care is warranted.

Non-dialysis care (NDC) is the provision of all aspects of renal care except for the dialysis process. While the nomenclature may vary, with terms such as ‘conservative care’, ‘maximal conservative management’ or ‘non-dialytic treatment’ having been associated with NDC, the clinical principle is to provide comprehensive care to patients who opt to forgo dialysis despite increasing uraemic symptoms. NDC therapies focus on pain relief, the use of erythropoietin-stimulating agents, anti-pruritics and anti-nausea therapies, with lower emphasis on strategies used to modulate the rate of renal progression. Patient selection remains the most challenging aspect of developing an NDC program, with selection often being based on physician instinct, family principles and population-based prognostic risk measures. Outcomes are fair with a significant proportion of NDC patients experiencing lower hospitalization days and higher rates of death at home (or in a preferred environment) rather than in acute-care hospitals.

For those patients with CKD followed in a pre-dialysis environment, it is well appreciated that modality education leads to an informed decision regarding type of dialysis selected. However, for those individuals starting dialysis acutely and requiring chronic renal replacement therapy, modality education may be lacking. Because of the acuity of the dialysis start, and the intercurrent illness or event which precipitated and acute start, these patients require a specialized approach to education, and indeed, require a combination of education and support to learn about and choose a renal replacement therapy. The University Health Network, in Toronto, Canada, has developed a program and approach to education and support of this group of patients. The approach, results, and theoretical underpinnings of this program are reviewed, and a potential new "hybrid" educational framework is proposed.

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