Background: Renal replacement therapy (RRT) has not always been shown to benefit end-stage renal failure patients who are elderly or have multiple comorbidities in terms of survival or symptom control. Conservative management may be a viable alternative offering comparable health-related quality of life. Methods: This is a prospective observational study of 101 patients who reached an estimated glomerular filtration rate of 8-12 ml/min and were either ≥75 years old or had an age-adjusted Charlson Comorbidity Index ≥8. Patients were all initially on conservative management; 38 later commenced renal replacement therapy while the rest remained conservatively managed. The Kidney Disease Quality of Life-Short Form was assessed at baseline and various scheduled time points over 24 months. The mixed model methodology was used to estimate the quality of life patterns and adjust for covariates. Results: In the conservative management group, the Physical Component Summary and Mental Component Summary scores were stable and showed no significantly different trajectories from the RRT group (both p > 0.05). Though RRT was associated with an improvement in the Cognitive Function Scale score, it was also associated with worse scores on the Effect of Kidney Disease and Burden of Kidney Disease Scale scores. Conclusions: RRT does not improve health-related quality of life of end-stage kidney failure patients who are elderly or have a high comorbidity burden.

BackgroundFor patients unable to receive heparin anticoagulation during haemodialysis, saline flushes to reduce circuit clotting are often the norm. Regional citrate anticoagulation (RCA) although effective is not used by many centres including in Singapore. We wanted to demonstrate the superiority and safety of a simple regional citrate anticoagulation regime, compared to saline flushes, for heparin-free low flux haemodialysis.MethodsThis is a prospective, open label, cross over study on 25 sequential haemodialysis sessions for inpatients receiving heparin-free haemodialysis. Patients were allocated either to regional citrate anticoagulation or standard heparin free haemodialysis and subsequently cross over to the alternate method. RCA was carried out using a protocol derived from previous studies. Assessment of anticoagulation was performed using visual inspection of clot formation in dialysis circuits and post-filter ionized calcium (iCa2+) using point-of-care Ionized calcium device at stipulated intervals. Intravenous Calcium gluconate replacement was given to patients receiving citrate adjusting the rate according to pre-filter iCa2+. Laboratory analyses of electrolytes were also assessed at the start and end of the RCA sessions.ResultsThere were no clots in the RCA arm, with 79% (n = 19) in the saline flush arm having some clot, including 1 clotted circuit. Post-filter iCa2+ at various time points were within acceptable range.Electrolyte readings in the RCA group were all within normal limits except for 4 cases of total Calcium:iCa2+ ratio > 2.5.ConclusionRCA is confirmed to be superior to saline flushes for circuit patency. We have a simple and safe protocol that can be followed for low flux haemodialysis.The study was approved by Singapore National Health Group domain-specific ethnical committee. NHG DSRB reference number 2014/01037.Trial registrationTrial registration number: ISRCTN69952745 (registration date 8/11/17).

Day care service is effective in alleviating the burden of caregivers and beneficial to patients with relatively good functional status. However, persuading patients and their caregivers to take up the program was a challenge.

After adjusting for demographic, SES, and other factors, ethnicity remained an important factor influencing HRQoL of Singaporean HD patients. Further studies are needed to identify modifiable factors that might explain the interethnic differences in HRQoL among HD patients.