Adverse Technical Events in Home Hemodialysis

doi:10.1053/j.ajkd.2014.08.013

American Journal of Kidney Diseases

Volume 65, Issue 1, January 2015, Pages 116-121

https://doi.org/10.1053/j.ajkd.2014.08.013 Get rights and content

Background

There is a growing interest in home hemodialysis because of its clinical benefits. However, given that patients are responsible for performing a complex medical procedure at home, adverse-event reporting is important to ensure patient safety. The purpose of this study was to describe adverse technical events in a large cohort of home hemodialysis patients.

Study Design

Retrospective cohort study.

Setting & Participants

All consecutive patients undergoing home hemodialysis at a large tertiary-care center from 1999 through 2011 (last follow-up, July 2012).

Outcomes

Overall rate of adverse technical events and number/rate of severe adverse events (defined as those requiring intervention).

Results

The cohort consisted of 202 patients with total follow-up of 757 patient-years. The cohort underwent a median of 5 dialysis treatments per week and 8 hours per session. 22 first adverse events and 7 recurrent events were identified. Adverse event rates were 0.049 per arteriovenous fistula access-year, 0.015 per arteriovenous graft access-year, and 0.022 per dialysis catheter access-year. Event rates per 1,000 dialysis treatments were 0.208, 0.068, and 0.087 for arteriovenous fistula, arteriovenous graft, and dialysis catheter access, respectively. Most adverse events were related to needle dislodgement (n = 18) or air embolism (n = 6). 8 adverse events resulted in emergency department visits and 5 required hospital admission. The rate of severe adverse events was 0.009 per patient-year of home hemodialysis and 0.038 per 1,000 dialysis treatments. Interventions included 3 blood transfusions, 2 catheter changes, 1 use of intravenous fluids, and 1 need for urgent dialysis. Attempts were made to retrain or review the technique in all patients with a first adverse event.

Limitations

Events that were not severe may have been under-reported by patients.

Conclusions

Serious adverse technical events in home hemodialysis are relatively rare. Strategies to further prevent these events may include patient retraining and periodic vascular access technique audit.

Section snippets

Study Population

The cohort consisted of all consecutive adult patients who initiated and completed HHD training at the University Health Network, Toronto General Hospital HHD training facility (Toronto, Ontario, Canada) from January 1, 1999, through December 31, 2011, with a date of last follow-up of July 1, 2012. We included patients who were receiving conventional HHD (3-5 hours, 3 treatments per week), intensive HHD (defined as an initial HHD prescription of ≥ 16 hours per week), and short daily hemodialysis

Cohort

The cohort consisted of 202 HHD patients. Characteristics of the complete cohort and patients with or without an event are shown in Table 1. Most (79%) events occurred among patients with an arteriovenous fistula. The other patient characteristics at the start of HHD training were similar.

Events

There were 22 first events and 7 recurrent events (total follow-up of 757 patient-years and 183,603 dialysis treatments). Characteristics of events are noted in Table 2. Four patients with an event (18%) were

Discussion

In this study of HHD patients, we identified that the overall rate of adverse technical events is low. Furthermore, when we considered only severe events (those requiring intervention), an even lower rate was appreciated. Appropriate identification and attempts at retraining were made in all patients after adverse events; however, even in those who were retrained, events recurred.

This study provides further evidence that catastrophic events (including those that are not severe and do not

Acknowledgements

Support: None.

Financial Disclosure: The authors declare that they have no relevant financial interests.

Contributions: Research idea and study design: KKT, CD’G, RF, SF, EW, CTC; data acquisition: KKT, CD’G, RF, SF, EW, CTC; data analysis/interpretation: KKT, CTC; statistical analysis: KKT. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity

References (17)

F.O. Finkelstein et al.
At-home short daily hemodialysis improves the long-term health-related quality of life
Kidney Int
(2012)
M.R. Marshall et al.
Home hemodialysis and mortality risk in Australian and New Zealand populations
Am J Kidney Dis
(2011)
B. Wong et al.
Procedure-related serious adverse events among home hemodialysis patients: a quality assurance perspective
Am J Kidney Dis
(2014)
M.E. Charlson et al.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation
J Chronic Dis
(1987)
B.F. Culleton et al.
The impact of short daily and nocturnal hemodialysis on quality of life, cardiovascular risk and survival
J Nephrol
(2011)
G.E. Nesrallah et al.
Intensive hemodialysis associates with improved survival compared with conventional hemodialysis
J Am Soc Nephrol
(2012)
E.D. Weinhandl et al.
Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients
J Am Soc Nephrol
(2012)
M.P. Kooistra et al.
Daily home haemodialysis in the Netherlands: effects on metabolic control, haemodynamics, and quality of life
Nephrol Dial Transplant
(1998)

There are more references available in the full text version of this article.

Cited by (43)

Extracorporeal Treatment for Gabapentin and Pregabalin Poisoning: Systematic Review and Recommendations From the EXTRIP Workgroup
2022, American Journal of Kidney Diseases
Citation Excerpt :
One patient developed complications of ECTR, namely thrombocytopenia from hemoperfusion-hemodialysis and a hematoma from catheter insertion.26 ECTR is known to be associated with significant costs142 and potential for complications related to the insertion of central venous catheter and the extracorporeal procedure.8,143-145 No patients with gabapentinoid withdrawal were reported after ECTR.
Toxicity from gabapentin and pregabalin overdose is commonly encountered. Treatment is supportive, and the use of extracorporeal treatments (ECTRs) is controversial. The EXTRIP workgroup conducted systematic reviews of the literature and summarized findings following published methods. Thirty-three articles (30 patient reports and 3 pharmacokinetic studies) met the inclusion criteria. High gabapentinoid extracorporeal clearance (>150 mL/min) and short elimination half-life (<5 hours) were reported with hemodialysis. The workgroup assessed gabapentin and pregabalin as “dialyzable” for patients with decreased kidney function (quality of the evidence grade as A and B, respectively). Limited clinical data were available (24 patients with gabapentin toxicity and 7 with pregabalin toxicity received ECTR). Severe toxicity, mortality, and sequelae were rare in cases receiving ECTR and in historical controls receiving standard care alone. No clear clinical benefit from ECTR could be identified although major knowledge gaps were acknowledged, as well as costs and harms of ECTR. The EXTRIP workgroup suggests against performing ECTR in addition to standard care rather than standard care alone (weak recommendation, very low quality of evidence) for gabapentinoid poisoning in patients with normal kidney function. If decreased kidney function and coma requiring mechanical ventilation are present, the workgroup suggests performing ECTR in addition to standard care (weak recommendation, very low quality of evidence).
Mathematical and computational modeling of device-induced thrombosis
2021, Current Opinion in Biomedical Engineering
Given the extensive and routine use of cardiovascular devices, a major limiting factor to their success is the thrombotic rate that occurs. This poses direct risk to the patient and requires counterbalancing with anticoagulation and other treatment strategies, contributing additional risks. Developing a better understanding of the mechanisms of device-induced thrombosis to aid in device design and medical management of patients is critical to advance the ubiquitous use and durability. Thus, mathematical and computational modeling of device-induced thrombosis has received significant attention recently, but challenges remain. Additional areas that need to be explored include microscopic/macroscopic approaches, reconciling physical and numerical timescales, immune/inflammatory responses, experimental validation, and incorporating pathologies and blood conditions. Addressing these areas will provide engineers and clinicians the tools to provide safe and effective cardiovascular devices.
Recommendations from the EXTRIP workgroup on extracorporeal treatment for baclofen poisoning
2021, Kidney International
Baclofen toxicity results from intentional self-poisoning (acute baclofen poisoning) or accumulation of therapeutic dose in the setting of impaired kidney function. Standard care includes baclofen discontinuation, respiratory support and seizure treatment. Use of extracorporeal treatments (ECTRs) is controversial. To clarify this, a comprehensive review of the literature on the effect of ECTRs in baclofen toxicity was performed and recommendations following EXTRIP methods were formulated based on 43 studies (1 comparative cohort, 1 aggregate results cohort, 1 pharmacokinetic modeling, and 40 patient reports or series). Toxicokinetic data were available for 20 patients. Baclofen’s dialyzability is limited by a high endogenous clearance and a short half-life in patients with normal kidney function. The workgroup assessed baclofen as “Moderately dialyzable” by intermittent hemodialysis for patients with normal kidney function (quality of evidence C) and “Dialyzable” for patients with impaired kidney function (quality of evidence C). Clinical data were available for 25 patients with acute baclofen poisoning and 46 patients with toxicity from therapeutic baclofen in kidney impairment. No deaths or sequelae were reported. Mortality in historical controls was rare. No benefit of ECTR was identified in patients with acute baclofen poisoning. Indirect evidence suggests a benefit of ECTR in reducing the duration of toxic encephalopathy from therapeutic baclofen in kidney impairment. These potential benefits were balanced against added costs and harms related to the insertion of a catheter, the procedure itself, and the potential of baclofen withdrawal. Thus, the EXTRIP workgroup suggests against performing ECTR in addition to standard care for acute baclofen poisoning and suggests performing ECTR in toxicity from therapeutic baclofen in kidney impairment, especially in the presence of coma requiring mechanical ventilation.
Survival comparisons in home hemodialysis: Understanding the present and looking to the future
2021, Nephrologie et Therapeutique
A number of studies have compared relative survival for home hemodialysis patients (including longer hours/more frequent schedules) and other forms of renal replacement therapy. While informative, many of these studies have been limited by issues pertaining to their observational design including selection bias and residual confounding. Furthermore the few randomized controlled trials that have been conducted have been underpowered to detect a survival difference. Finally, in the face of a growing recognition of the value of patient-important outcomes beyond survival, the focus of comparisons between dialysis modalities may be changing. In this review, we will discuss the determinants of survival for patients receiving home hemodialysis and address the various studies that have compared relative survival for differing home hemodialysis schedules to each of in-center hemodialysis, peritoneal dialysis and transplantation. We will conclude this review by discussing whether there is an ongoing role for survival analyses in home hemodialysis.
Physical Infrastructure and Integrated Governance Structure for Home Hemodialysis
2021, Advances in Chronic Kidney Disease
Citation Excerpt :
This shows the importance of strong follow-up care from the nursing team. Routine vascular access audit and systematic annual or semi-annual retraining may also help to proactively identify technical errors that may have otherwise precipitated HHD technique failure.38,39 Close monitoring of patients undergoing HHD is also essential to avoid patient burnout and unplanned return to in-center hemodialysis.7
In view of the growing enthusiasm for home dialysis use, new dialysis centers may build or expend their home hemodialysis program in the next few years. This review will discuss the main challenges faced by small and large home hemodialysis programs in terms of physical spaces, human resource, training considerations, and overall governance. We will elaborate on the inclusion of home hemodialysis in the kidney replacement therapy care continuum, with a specific interest for collaboration and transition between peritoneal dialysis and home hemodialysis programs.
Quality Assurance and Preventing Serious Adverse Events in the Home Hemodialysis Setting
2021, Advances in Chronic Kidney Disease
Citation Excerpt :
Some of the difficulty in characterizing these events relates to the how they are defined and how well they are captured. Notwithstanding this limitation, only a few studies have aimed to characterize and quantify noninfectious adverse procedure-related events in HHD, some of which are summarized in Table 1.4,5,19 Wong and colleagues5 identified that life-threatening procedure-related adverse events occurred at a very low rate (14/1000 patient-years).
Patient safety is of the utmost importance in home hemodialysis (HHD). Recognizing that there are risks related to vascular access (both infectious and noninfectious events), dialysis water quality, and procedural-related adverse events (including arteriovenous fistula needle dislodgement or air embolism), there is a need for systematic identification and management. Although adverse events are relatively infrequent in HHD, the potential consequences of these events may include significant morbidity, HHD treatment failure, or death. Therefore, having a systematic framework to review each event, audit and retrain patient technique, disclose and discuss events with patients, home unit staff and device companies (if relevant) and determine preventative measures to avoid future adverse events, is crucial. In this review, we will describe the literature around the types and relative frequency of serious adverse events in the HHD setting and we will outline a quality assurance framework for capturing, managing, and avoiding serious adverse events. Finally, we will describe some of the novel existing approaches to preventing or addressing serious adverse events and critical knowledge gaps that should be evaluated in future study.

View all citing articles on Scopus

View full text

Original InvestigationDialysisAdverse Technical Events in Home Hemodialysis

Background

Study Design

Setting & Participants

Outcomes

Results

Limitations

Conclusions

Section snippets

Study Population

Cohort

Events

Discussion

Acknowledgements

Kidney Int

Am J Kidney Dis

Am J Kidney Dis

J Chronic Dis

The impact of short daily and nocturnal hemodialysis on quality of life, cardiovascular risk and survival

J Nephrol

Intensive hemodialysis associates with improved survival compared with conventional hemodialysis

J Am Soc Nephrol

Survival in daily home hemodialysis and matched thrice-weekly in-center hemodialysis patients

J Am Soc Nephrol

Daily home haemodialysis in the Netherlands: effects on metabolic control, haemodynamics, and quality of life

Nephrol Dial Transplant

Original Investigation
Dialysis
Adverse Technical Events in Home Hemodialysis