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BackgroundRates of End-Stage Kidney Disease among Aboriginal and Torres Strait Islander (Indigenous) Australians in remote areas are disproportionately high; however, haemodialysis is not currently offered in most remote areas. People must therefore leave their ‘Country’ (with its traditions and supports) and relocate to metropolitan or regional centres, disrupting their kinship and the cultural ties that are important for their wellbeing. The South Australian Mobile Dialysis Truck is a service which visits remote communities for one to two week periods; allowing patients to have dialysis on ‘Country’, reuniting them with their friends and family, and providing a chance to take part in cultural activities. The aims of the study were to qualitatively evaluate the South Australian Mobile Dialysis Truck program, its impact on the health and wellbeing of Indigenous dialysis patients, and the facilitators and barriers to using the service.MethodsFace to face semi-structured interviews were conducted with 15 Indigenous dialysis patients and 10 nurses who had attended trips across nine dialysis units. Realist evaluation methodology and thematic analysis established patient and nursing experiences with the Mobile Dialysis Truck.ResultsThe consequences of leaving Country included grief and loss. Barriers to trip attendance included lower trip frequencies, ineffective trip advertisement, lack of appropriate or unavailable accommodation for staff and patients and poor patient health. Benefits of the service included the ability to fulfil cultural commitments, minimisation of medical retrievals from patients missing dialysis to return to remote areas, improved trust and relationships between patients and staff, and improved patient quality of life. The bus also provided a valuable cultural learning opportunity for staff. Facilitators to successful trips included support staff, clinical back-up and a co-ordinator role.ConclusionsThe Mobile Dialysis Truck was found to improve the social and emotional wellbeing of Indigenous patients who have had to relocate for dialysis, and build positive relationships and trust between metropolitan nurses and remote patients. The trust fostered improved engagement with associated health services. It also provided valuable cultural learning opportunities for nursing staff. This format of health service may improve cultural competencies with nursing staff who provide regular care for Indigenous patients.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3849-4) contains supplementary material, which is available to authorized users.

Background: To measure health-related and care-related quality of life among informal caregivers of older people with end-stage kidney disease (ESKD), and to determine the association between caregiver quality of life and care recipient's treatment type. Methods: A prospective cross-sectional study was conducted. Three renal units in the UK and Australia were included. Informal caregivers of people aged ≥75 years with ESKD managed with dialysis or comprehensive conservative non-dialytic care (estimated glomerular filtration (eGFR) ≤10 mL/min/1.73m 2) participated. Healthrelated quality of life (HRQoL) was assessed using Short-Form six dimensions (SF-6D, 0-1 scale) and care-related quality of life was assessed using the Carer Experience Scale (CES, 0-100 scale). Linear regression assessed associations between care-recipient treatment type, caregiver characteristics and the SF-6D utility index and CES scores. Results: Of 63 caregivers, 49 (78%) were from Australia, 26 (41%) cared for an older person managed with dialysis, and 37 (59%) cared for an older person managed with comprehensive conservative care. Overall, 73% were females, and the median age of the entire cohort was 76 years [IQR 68-81]. When adjusted for caregiver sociodemographic characteristics, caregivers reported significantly worse carer experience (CES score 15.73, 95% CI 5.78 to 25.68) for those managing an older person on dialysis compared with conservative care. However, no significant difference observed for carer HRQoL (SF-6D utility index − 0.08, 95% CI − 0.18 to 0.01) for those managing an older person on dialysis compared with conservative care. Conclusions: Our data suggest informal caregivers of older people on dialysis have significantly worse care-related quality of life (and therefore greater need for support) than those managed with comprehensive conservative care. It is important to consider the impact on caregivers' quality of life when considering treatment choices for their care recipients.

BackgroundIdentification of people with deteriorating health is essential for quality patient-centred care and optimal management. The Supportive and Palliative Care Indicators Tool (SPICT) is a guide to identifying people with deteriorating health for care planning without incorporating a prognostic time frame.ObjectivesTo improve renal nursing staff confidence in identifying patients approaching end-of-life and advocate for appropriate multidisciplinary care planning.DesignThis pilot feasibility prospective cohort study conducted in the renal ward of a major metropolitan health service during 2019 included a preintervention/postintervention survey questionnaire. A programme of education was implemented training staff to recognise end-of-life and facilitate appropriate care planning.ResultsSeveral domains in the postintervention survey demonstrated a statistically significant improvement in renal nurses’ perception of confidence in their ability to recognise end of life. Of the 210 patients admitted during the study period, 16% were recognised as SPICT positive triggering renal physicians to initiate discussions about end-of-life care planning with patients and their families and to document a plan. Six months poststudy, 72% of those patients recognised as SPICT positive had died with a documented plan of care in place.ConclusionThe use of SPICT for hospital admissions and the application of education in topics related to end-of-life care resulted in a significant improvement in nurses’ confidence in recognising deteriorating and frail patients approaching their end of life. The use of this tool also increased the number of deteriorating patients approaching end of life with goals of care documented.

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A n 80-year-old woman presented with left leg pain. She had end-stage renal disease caused by hypertensive nephrosclerosis and was undergoing maintenance hemodialysis. A radiograph of the pelvis and femur revealed extensive calcifications (arrow) in the muscles and subcutaneous tissues of the lower abdominal wall, gluteal regions, and outer thighs, in addition to vascular calcification (arrowhead) and osteopenia. There was no evidence of fracture. The patient was receiving warfarin because of atrial fibrillation. She also had secondary hyperparathyroidism due to renal failure; a month before the administration of cinacalcet was begun, she had a parathyroid hormone level of 73.1 pmol per liter (normal range, 0.8 to 5.5) and a product of the calcium level times the phosphorus level of 5.2 mmol 2 per square liter (65 mg 2 per square deciliter; reference range, <4.4 mmol 2 per square liter [<55 mg 2 per square deciliter]). Secondary hyperparathyroidism, a high calcium-phosphorus product, and warfarin have been associated with metastatic calcification and calcific uremic arteriolopathy (calciphylaxis), especially in patients undergoing dialysis. Warfarin inhibits γ-carboxylation of matrix Gla protein (a protein that inhibits calcification). The administration of warfarin was stopped, and aggressive management of calcium and phosphorus levels was continued. Although the biochemical variables improved, the patient continues to have pain, which is a notable feature of calcific uremic arteriolopathy. Attempts to manage her pain continue.

• Patients with ESKD, with or without RRT, are heavily burdened with symptoms which may interact and compound each other. The burden of symptoms experienced by patients on dialysis is rarely mentioned in patient information sheets despite being well documented in research data. Patients with End-Stage Kidney Disease (ESKD) whether or not on renal replacement therapy (RRT) have considerable prevalence of symptoms. Indeed this group is among the most heavily burdened of any disease group (1-3). A large, systematic review of prevalence studies of symptoms (4), experienced by dialysis patients showed a significant burden of symptoms. A subsequent study by the same group found a similar prevalence of symptoms in patients being managed conservatively (5). A summary of the results of those studies appears below in Table 1

This study has demonstrated that younger age and comorbid diabetes were responsible for a statistically significant reduction in quality of life, and HDF did not confer any advantage.