Renal Society of Australasia Journal

Aim Clinical guidelines recommend using bioelectrical impedance analysis (BIA) to assess body composition in adults with renal failure on maintenance haemodialysis. This study evaluated the feasibility, acceptability and clinical utility of using BIA with haemodialysis outpatients.

Methods Patients attending the haemodialysis outpatient unit at a tertiary public hospital in Australia were consecutively recruited. Participants completed a pre- and post-dialysis BIA measure and satisfaction survey about the measurement process. Primary outcomes pertained to feasibility (recruitment and measurement completion rates). Secondary outcomes included acceptability, assessed via patient satisfaction surveys, and predictive value of BIA for identifying malnutrition according to Subjective Global Assessment (SGA). Continuous variables were presented as mean ± standard deviation (or median and interquartile range). Binomial logistic regression was performed to determine the predictive value of BIA for identifying malnutrition. Receiver operating characteristic curve analysis was used to evaluate BIA parameters for their ability to discriminate malnourished patients (determined by SGA) from well-nourished patients. Statistical significance was established at p<0.05.

Results A total of 30 of 36 patients approached (83%) consented to participate, with 28 completing at least one BIA measurement and included in data analysis. BIA measurement completion rates were 93% and 87% pre- and post-dialysis, respectively. Post-dialysis BIA measures of fat mass index, fat free mass index and skeletal muscle mass most closely reflected SGA-categorised malnutrition. Patients reported high acceptability for BIA, found the process easy, and valued the results.

Conclusion BIA use in an outpatient haemodialysis unit is feasible and acceptable to patients, providing valuable objective data to enhance clinical practice.

Aim This scoping review aims to identify and map the extent of published literature on Hepatitis B vaccination in stage 4/5 chronic kidney disease (CKD) and dialysis patients, the availability of standardised practice guidelines, the optimal CKD stage to commence the vaccination for efficient response, and seroconversion rate.

Background Hepatitis B vaccination remains ‘standard-of-care’ in the haemodialysis (HD) population despite immunological challenges. CKD patients have decreasing immunity as the disease progresses, prompting further research to investigate the response of Hepatitis B vaccination in earlier stages of CKD for better response rate prior to requiring dialysis.

Method This scoping review was conducted using the Arksey and O’Malley (2005) five-stage approach: 1) identifying the research question; 2) identifying the relevant studies; 3) selecting the studies; 4) data charting; and 5) collating, summarising and reporting the results. Medline, PubMed, PubMed Central (PMC) and Cochrane databases were used to access research literature published between 2012–2022.

Results Of the 602 eligible articles,183 full text papers were identified. There were 41 studies retained for this review which were sorted out into domains relating to the vaccine immunogenicity, vaccine response and clinical practice guidelines. Although there were studies suggesting immunosuppression in declining renal function leads to low vaccine response, most of the studies were focused on HD patients. There have been no large, randomised control trials on optimal vaccination policy in CKD patients. This scoping review provided important knowledge for future studies to explore the efficiency of commencing vaccination at an earlier stage of CKD before reaching dialysis.

Background Post-dilution haemodiafiltration (post-HDF) is highly efficient in terms of solute clearance but haemoconcentration and dialysis circuit clotting potentially inhibit its clinical application.

Objectives Mixed-dilution HDF (mixed-HDF), developed to permit simultaneous pre- and post-fluid delivery, has been proposed to deliver higher total convection volumes and other associated benefits. We explored potential benefits of mixed-HDF.

Design/participants In this prospective, open label, randomised, cross-over study, patients were randomised to receive, after a 2-week wash-in period of control therapy (post-HDF), 4 weeks of the control therapy (post-HDF) first (intervention period 1), followed by a 2-week wash-out period, and then 4 weeks of experimental therapy (mixed-HDF) (intervention period 2), or vice versa.

Measurements The primary outcome was total convention volume. Secondary outcomes were differences in transmembrane pressures (TMP), circuit clotting, small and middle molecule clearances and post-dialysis recovery times.

Results A total of 25 patients were recruited from two Australian dialysis centres, with 22 patients completing the study (mean age 62.5 years, 63.6% male, 36.4% diabetes). Total convection volumes were significantly higher with mixed-HDF (39.0L) compared to post-HDF (21.9L; difference 17.5L, 95% CI 15.47–18.64L, p<0.001). There were no significant differences in any of the secondary outcomes. No safety issues were identified.

Conclusion Convection volumes significantly increased with mixed-HDF but solute clearances and post-dialysis recovery times were not different to post-HDF. Longer studies will be required to determine whether the higher convention volume results in clinically significant improvements in outcomes.

Objective Australia is currently experiencing a shortage of nursing staff that will have a negative impact on nursing specialties. We examined the current Australian and New Zealand nephrology nursing workforce for measures of burnout as well as for the features of ‘magnet’ qualities that can attract staff, support the workforce and reduce attrition.

Methods A co-designed 57-item survey was distributed to the nephrology nursing workforce online through membership of the Renal Society of Australasia. The survey used the Oldenburg Burnout Inventory (OLBI) and included a discreet choice experiment (DCE) in which respondents are offered different choices, blinded to the intention, and asked to rank in order of highest priority what they considered to be the most valuable organisational attributes.

Results The 253 respondents to the OLBI described moderate burnout (mean score 40.4); however, the respondents were mostly still able to describe feeling a sense of achievement most days. For the 143 respondents who completed the DCE, they chose professional educational opportunities to be ranked number one as the most important organisational attribute for recruiting and retaining nephrology nurses, with options for career progression ranked number two.

Conclusion The sustainability of the nephrology nursing profession depends upon organisations recognising burnout in their workforce and taking action to incorporate ‘magnet’ qualities to increase professional education opportunities and career progression opportunities to stabilise the workforce.

Context The ‘inaugural’ Caring for Australian and New Zealanders with Kidney Impairment (CARI) guidelines for First Nations Australians provide recommendations on caring for First Nations Peoples with chronic kidney disease (CKD). Informed by targeted national community consultations, the guidelines include the historical context, detailed advice on culturally safe kidney healthcare, screening and referral of CKD. Public awareness and education initiatives, self-management programs, and models of care are all reported on.

Objectives The CARI guidelines were developed in response to significant challenges and inequities experienced by First Nations Peoples over many years. Specific recommendations and suggestions aim to improve clinicians’ understanding of historical and contemporary factors contributing to the social and health inequities underpinning the over-representation of First Nations Peoples with CKD. These guidelines provide comprehensive support for health professionals in all service and care environments to better respond to the care needs of First Nations Peoples.

Key findings The CARI guidelines highlight the need to provide culturally safe clinical care and explicitly cite the need to address institutional racism and improve cultural safety training for all renal service providers. They specifically recognise the importance of kinship, and equitable access to transport and accommodation services. They also focus on keeping people on Country where possible, including increased nurse-supported and Aboriginal health practitioner-supported dialysis services.

Conclusion The CARI guidelines provide recommendations on how to improve clinical kidney care delivery for and with First Nations Peoples by ensuring more responsive models of care.

Background Quality dialysis care is associated with appropriate staffing levels of trained and educated health professionals. Dialysis workforce models are rapidly changing, requiring workforce analysis to be performed.

Aim To identify current Australian and New Zealand dialysis workforce characteristics and trends.

Method A 21-question web-based survey was disseminated to dialysis unit managers across Australia and New Zealand.

Results A total of 205 unit responses were received (response rate 51%). The Australia and New Zealand dialysis workforce consisted of registered nurses (90%), enrolled nurses (6%) and clinical renal physiologists/patient care technicians (4%). The median age of dialysis staff was 45 years, and 37% of staff had formal nationally accredited renal qualifications. Most units had access to a renal educator (71%). The majority of units used patient to staff ratios (90% with an average of 1:3.3); however, only around one third measured patient acuity (38%). Unit managers reported that they always or usually have enough staff (68%), and offered overtime (75%) and called in current staff (63%) to cover vacancies.

Conclusion This study has provided a ‘snapshot’ of the dialysis workforce. It identified dialysis unit and workforce growth, though not at the same rate as patient growth. The dialysis workforce is older, and there is an increasing reliance on the good will of current staff to cover shift vacancies. Tracking trends in the dialysis workforce may be useful in assisting these and future challenges, education and retention strategies to maintain and improve patient care both locally and globally.

Dyspnoea in patients with chronic kidney disease (CKD) receiving haemodialysis (HD) is common, and caused negative impacts during the COVID‑19 pandemic. This study aimed to explore dyspnoea experience and management strategies in Thai HD patients during the COVID‑19 pandemic. A qualitative descriptive approach was conducted. Purposive sampling was used to recruit 20 participants from three regional hospitals in Thailand, and data were collected using face-to-face, individual semi-structured interviews. Data were analysed using a qualitative content analysis method.

The study results revealed two main themes and six sub-themes. The first is the experience of dyspnoea during the COVID‑19 pandemic, including: being afraid of contracting COVID‑19, leading to severe dyspnoea and death; difficulty controlling fluid and food intake; and reducing HD cycles. The second concerned dyspnoea management during the COVID‑19 pandemic, including: changing dietary behaviour; applying religious teaching; and receiving more help from family members. This study reflects how Thai culture is influenced by both religion and family support. Nurses play an important role in helping and managing patients’ dyspnoea symptoms, allowing patients receiving HD to fulfil their daily life goals during the COVID‑19 pandemic.

Background The extracorporeal circuit, which is all the apparatus for carrying a patient’s blood outside the body – for example, intravenous cannulas, dialysis tubing, membranes and lines – will clot due to inadequate anticoagulation or blood flow, as well as due to air in the circuit. Clotting of circuits result in blood loss, interrupted dialysis treatments and poor solute clearances. Therefore, anticoagulation agents such as regional citrate anticoagulants (RCA), low molecular weight heparins (LMWH) and 0.9% sodium chloride (0.9% NaCl) are often used to prevent circuit clotting.

Aim The aim of this study is to investigate whether RCA are more effective in preventing or reducing clots in the extracorporeal circuit compared to LMWH and 0.9% NaCl in adult renal replacement therapy (RRT) patients.

Methods Peer reviewed papers published in English between January 2010 to December 2021 were considered for this review. The patient population included haemodialysis (HD) patients 18 years and older. Paediatric HD patients were excluded.

Results A total of 16 studies were selected for this review, with evidence levels ranging from primary evidence Levels II & III to secondary evidence Levels I & II. The findings of this study show that citrates do not affect systemic coagulation and have a reduced bleeding risk than systemic anticoagulants. However, citrates can cause citrate toxicity in critically ill patients. Patients dialysing with 0.9% NaCl flushes and without anticoagulation of any kind, that is systemic or regional, clotted their extracorporeal circuits. The consensus of the findings from most of the studies included in this review is that LMWH, for example enaxoparin, can be administered quickly and has a low risk of dosing mistakes due to the prefilled single dose syringes used in Australia.

Conclusion The findings of this study underscore the importance of continuing using LMWH for anticoagulation in unsupported centres without adequate protocols, for example satellite clinics. Overall, having reviewed the literature, it can be said that citrate is safe and efficacious, reducing bleeding and clotting of circuits.

Patients with kidney failure choosing peritoneal dialysis (PD) as their kidney replacement therapy (KRT) frequently experience high symptom burden and reduced health-related quality of life (HRQoL) due to their disease process and the requirements of their dialysis regimen. Achieving shared decision making and finding balance for individual patients between maximising therapy and maintaining patients’ HRQoL requires optimal assessment, clear communication of patients’ priorities and integration of this information into patients’ dialysis regimens to improve the outcomes that are prioritised by patients. Defining the outcomes that are prioritised by patients and their carers is also required to develop a standardised approach to allow for integration of patient-reported outcome measures (PROMs) into patient care. Assessment of HRQoL is best achieved by utilising PROMs; however, multiple PROMs exist and there is currently no consensus from national and international guidelines on a standardised approach to utilising PROMs for patients on PD. The aim of this review is to analyse the literature regarding the use of PROMs for patients on PD to gain a greater understanding of how to guide care and improve patient outcomes.