Advances in Human-Centered Care to Address Contemporary Unmet Needs in Chronic Dialysis

Abstract

Advances in the treatment of kidney failure with chronic dialysis have stagnated over the past three decades, with over 50% of patients still managed by conventional in-hospital haemodialysis. In parallel, the demands of chronic dialysis medical care have changed and evolved due to a growing population that has higher frailty and multimorbidity. Thus, the gap between the needs of kidney failure patients and the healthcare capability to provide effective overall management has widened. To address this problem, healthcare policy has increasingly aligned towards a human-centred approach. The paradigm shift of human-centred approach places patients at the forefront of decision-making processes, ensuring that specific needs are understood and prioritised. Integration of human-centred approaches with patient care has been shown to improve satisfaction and quality of life. The aim of this narrative is to evaluate the current clinical challenges for managing kidney failure for dialysis providers; summarise current experiences and unmet needs of chronic dialysis patients; and finally emphasise how human-centred care has advanced chronic dialysis care. Specific incremental advances include implementation of renal supportive care; home-assisted dialysis; hybrid dialysis; refinements to dialysis methods; whereas emerging advances include portable and wearable dialysis devices and the potential for the integration of artificial intelligence in clinical practice.

Keywords: chronic dialysis; innovation; kidney failure; patient preference; patient-centred care; renal replacement therapy.

Figure 1

This figure shows the geographic locations of the Local Health Districts within Sydney. Reproduced from © State of New South Wales NSW Ministry of Health under the Creative Commons Attribution 4.0 licence. The Western Renal Service comprising the Western Sydney Local Health District and the Nepean Blue Mountains Local Health District serve a population of 1.3M and a total area of 9959 square kilometres.

Figure 2

This figure demonstrates the standard clinical pathways for kidney failure patients in the Western Renal Service. The ideal pathway is early referral from the general practitioner to a nephrologist for pre-dialysis medical care (eg treatment with ACE/ARB inhibitors, SGTL2 inhibitors and other measures) and assessment by the pre-dialysis educator to provide education and determine the optimal renal replacement plan with a preference for encouraging home-based treatments. Planning for dialysis involves surgical referral for either the creation of a fistula for haemodialysis (including Doppler vascular mapping) or consideration of insertion of a peritoneal dialysis catheter (either by laparoscopy or the Seldinger method). Recently, there has been a marked increase in patients who present with kidney failure without a prior plan who often require insertion of a tunnelled vascular catheter for acute start haemodialysis. Additionally, these patients can commence acute dialysis through peritoneal dialysis catheter insertion using the Seldinger method. Once established on chronic dialysis, patients undergo peritoneal dialysis; or haemodialysis either in-hospital, at a satellite centre or at home. Other management pathways include kidney transplantation or renal supportive care, and importantly patients can transition between these options at any time.

Figure 3

This figure demonstrates the factors that lead to an imbalance between an optimal healthcare system and patient satisfaction in the treatment of kidney failure. Rapid population growth in Sydney with increasing frailty multimorbidity, and cultural diversity are factors impacting service delivery in Western Sydney as well as most other high-resource healthcare systems across the world. Higher rates of sub-optimal healthcare literacy and financial disadvantage, have particularly negative impacts in the dialysis population, due to the complexity of the medical condition.