Letter to the Editor
Low rate of adverse events in home hemodialysis
Baja tasa de eventos adversos en hemodiálisis domiciliaria
Alejandro Pérez Alba
, Javier Reque Santiváñez, Alba Segarra Pedro, Silvia Torres Campos, Juan José Sánchez Canel, M. Ángeles Fenollosa Segarra, Ramón Pons Prades
Corresponding author
Hospital General de Castellón, Castellón de la Plana, Castellón, Spain
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Ángeles Fenollosa Segarra, Ramón Pons Prades" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Alejandro" "apellidos" => "Pérez Alba" "email" => array:1 [ 0 => "aperezalba@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Javier" "apellidos" => "Reque Santiváñez" ] 2 => array:2 [ "nombre" => "Alba" "apellidos" => "Segarra Pedro" ] 3 => array:2 [ "nombre" => "Silvia" "apellidos" => "Torres Campos" ] 4 => array:2 [ "nombre" => "Juan José" "apellidos" => "Sánchez Canel" ] 5 => array:2 [ "nombre" => "M. Ángeles" "apellidos" => "Fenollosa Segarra" ] 6 => array:2 [ "nombre" => "Ramón" "apellidos" => "Pons Prades" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital General de Castellón, Castellón de la Plana, Castellón, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Baja tasa de eventos adversos en hemodiálisis domiciliaria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1541 "Ancho" => 1714 "Tamanyo" => 82000 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Percentage of minor adverse events.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Currently due to the benefits reported with HHD,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2,3</span></a> there is growing interest in home haemodialysis (HHD).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In Spain, although the number of patients on HHD has increased in recent years, the percentage remains low,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> one of the main problems being that there is little familiarity with the technique<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> and the fear of adverse events (AE) is manifested. For this reason, we considered it appropriate to analyse the AEs observed in the HHD unit of our Hospital from the beginning of the programme in March 2008 until June 2017.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We consider a serious adverse event (SAE) the one that required some type of emergency action by medical professionals, being automatically reported by the patient to the hospital, usually over the phone. Minor adverse events (MAE) were recorded by the patient in the haemodialysis form, and we conducted a retrospective analysis of these.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Since the HHD programme was started, we have trained 35 patients, 32 were able to move home and 3 did not pass the training (2 patients lacked self confidence and one had associated comorbidity).</p><p id="par0020" class="elsevierStylePara elsevierViewall">Of the 32 patients on HHD: average age 57.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>13.1 years; Charlson index 4.1<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.7; 18 men, 14 women, 25% with diabetes mellitus.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Haemodialysis (HD) time/session was 149.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>16.1<span class="elsevierStyleHsp" style=""></span>min; frequency 5.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.5 sessions/week; weekly time 791.9<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>94.8<span class="elsevierStyleHsp" style=""></span>min; 14 NxStage systems and 18 conventional monitors; 20,034 days remaining at home (17,889 days/catheter and 2145 days/fistula).</p><p id="par0030" class="elsevierStylePara elsevierViewall">In total, 4 SAEs, 0.072 events/patient/year (0.275 SAEs/1000 HD sessions).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Two episodes occurred in the same 49-year-old patient, after 7 and 9 months on HHD. The first was hypotension with loss of consciousness and recovery after being disconnected by the carer, who called the emergency services and the patient was transferred to hospital without requiring admission. The second episode was a new hypotensive episode with loss of consciousness and seizure, with the carer again being present. Hospitalisation was required to rule out the possibility that the patient had stopped taking antiepileptic medication. In both cases, the patient was ultrafiltrating a greater quantity than recommended by our unit.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The third episode occurred in a 43-year-old patient who had been on HHD for less than 6 months. It was a clot in the circuit at the end of the HD session, which reached the tunnelled catheter, causing full obstruction thereof. The patient was transferred to hospital where we removed the obstruction with urokinase and the patient was not admitted.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The fourth episode was a new hypotensive episode in a 72-year-old patient, without loss of consciousness, but a call to the emergency services was required without transfer to hospital.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Regarding the MAEs, we retrospectively analysed 11,463 haemodialysis sessions (78.9% of the total HHD completed). In the remaining cases it was impossible for us to recover the information. We recorded 272 MAEs (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with a MAE rate of 23.72/1000 HD sessions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Forty-one hospitalisations occurred (24.4% scheduled), 0.747 admissions/patients/year (19.5% due to cardiovascular causes, 26.8% due to infectious causes not related to vascular access, and 12.2% due to infectious causes related to vascular access). Six infection events related to the haemodialysis catheter, 5 required hospital admission (0.12 infections/patient/year) and none in the arteriovenous fistula. Regarding vascular access dysfunctions recorded as such by the patient on HHD sheets, 16 were due to catheter (1.59/1000 HD, 8 required hospital HD), 13 were due to fistula (8.95/1000 HD, 10 required hospital HD), relative risk 5.6 (2.7–11.6).</p><p id="par0060" class="elsevierStylePara elsevierViewall">We did not record significant differences when we attempted to relate the MAE rates to patient age, Charlson [index], number of training sessions, and type of monitor used.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Patients required HD in a hospital unit, without considering admission episodes, for 454 days (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">We present a SAE rate similar to those described in the few existing series in the medical literature,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> although it depends what is considered as such, while Wong et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> describe it as a life-threatening event, Tennankore et al.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> consider it, like we did, as one requiring some kind of medical action. As for MAEs, data are also limited,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">7,8</span></a> again depending on what is considered a minor event, but our report is similar to previous publications.</p><p id="par0075" class="elsevierStylePara elsevierViewall">We consider that in each HHD unit there should be an ongoing record of AEs that occur,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> if possible in real time, in order to establish the control and feedback methods for said events, to generate strategies and action protocols in order to minimise them. In our case, we set lower ultrafiltration limits, always at 10<span class="elsevierStyleHsp" style=""></span>ml/kg/h. The exploration of the possibilities offered by telemedicine can provide great assistance in this regard.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Furthermore, in all HHD units there should also be a series of dialysis stations that ensure sessions are available at times when the patient cannot do it at home.</p><p id="par0085" class="elsevierStylePara elsevierViewall">We conclude that, despite being impossible to eradicate the possibility of AEs, the rate thereof is more than acceptable, making HHD a safe technique that can offer many benefits to patients.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez Alba A, Reque Santiváñez J, Segarra Pedro A, Torres Campos S, Sánchez Canel JJ, Fenollosa Segarra MÁ, et al. Baja tasa de eventos adversos en hemodiálisis domiciliaria. Nefrología. 2018;38:452–454.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1541 "Ancho" => 1714 "Tamanyo" => 82000 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Percentage of minor adverse events.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">HD: haemodialysis.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reason \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No. of frequency \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage of frequency \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Days \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Percentage of days \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Average no. of days \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Range of days \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Vascular access problem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–30 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Puncture training \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">149 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12–123 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Monitor problem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Water problem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Monitor replacement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.04 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">24.48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">181 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1–41 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1810212.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Outpatient HD needs at hospital unit.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "US renal data system 2013 annual data report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.J. 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| Year/Month | Html | Total | |
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| 2024 October | 38 | 44 | 82 |
| 2024 September | 42 | 24 | 66 |
| 2024 August | 53 | 57 | 110 |
| 2024 July | 38 | 33 | 71 |
| 2024 June | 50 | 39 | 89 |
| 2024 May | 36 | 16 | 52 |
| 2024 April | 49 | 24 | 73 |
| 2024 March | 31 | 21 | 52 |
| 2024 February | 39 | 37 | 76 |
| 2024 January | 38 | 24 | 62 |
| 2023 December | 30 | 43 | 73 |
| 2023 November | 38 | 54 | 92 |
| 2023 October | 50 | 30 | 80 |
| 2023 September | 40 | 27 | 67 |
| 2023 August | 34 | 16 | 50 |
| 2023 July | 45 | 35 | 80 |
| 2023 June | 40 | 26 | 66 |
| 2023 May | 52 | 168 | 220 |
| 2023 April | 25 | 12 | 37 |
| 2023 March | 46 | 18 | 64 |
| 2023 February | 39 | 19 | 58 |
| 2023 January | 42 | 26 | 68 |
| 2022 December | 65 | 32 | 97 |
| 2022 November | 48 | 37 | 85 |
| 2022 October | 65 | 42 | 107 |
| 2022 September | 37 | 31 | 68 |
| 2022 August | 42 | 56 | 98 |
| 2022 July | 38 | 67 | 105 |
| 2022 June | 28 | 31 | 59 |
| 2022 May | 48 | 43 | 91 |
| 2022 April | 44 | 51 | 95 |
| 2022 March | 48 | 57 | 105 |
| 2022 February | 46 | 56 | 102 |
| 2022 January | 43 | 35 | 78 |
| 2021 December | 49 | 41 | 90 |
| 2021 November | 44 | 43 | 87 |
| 2021 October | 46 | 41 | 87 |
| 2021 September | 34 | 39 | 73 |
| 2021 August | 34 | 43 | 77 |
| 2021 July | 27 | 41 | 68 |
| 2021 June | 33 | 33 | 66 |
| 2021 May | 79 | 52 | 131 |
| 2021 April | 92 | 60 | 152 |
| 2021 March | 52 | 33 | 85 |
| 2021 February | 46 | 38 | 84 |
| 2021 January | 41 | 26 | 67 |
| 2020 December | 41 | 21 | 62 |
| 2020 November | 27 | 16 | 43 |
| 2020 October | 25 | 19 | 44 |
| 2020 September | 29 | 17 | 46 |
| 2020 August | 35 | 12 | 47 |
| 2020 July | 31 | 13 | 44 |
| 2020 June | 47 | 19 | 66 |
| 2020 May | 48 | 11 | 59 |
| 2020 April | 35 | 22 | 57 |
| 2020 March | 45 | 13 | 58 |
| 2020 February | 31 | 22 | 53 |
| 2020 January | 54 | 28 | 82 |
| 2019 December | 38 | 25 | 63 |
| 2019 November | 37 | 26 | 63 |
| 2019 October | 27 | 16 | 43 |
| 2019 September | 31 | 15 | 46 |
| 2019 August | 37 | 22 | 59 |
| 2019 July | 43 | 29 | 72 |
| 2019 June | 45 | 32 | 77 |
| 2019 May | 49 | 24 | 73 |
| 2019 April | 75 | 38 | 113 |
| 2019 March | 37 | 28 | 65 |
| 2019 February | 17 | 15 | 32 |
| 2019 January | 38 | 20 | 58 |
| 2018 December | 83 | 42 | 125 |
| 2018 November | 104 | 16 | 120 |
| 2018 October | 64 | 12 | 76 |
| 2018 September | 55 | 13 | 68 |
| 2018 August | 65 | 16 | 81 |
| 2018 July | 44 | 8 | 52 |
| 2018 June | 55 | 10 | 65 |
| 2018 May | 41 | 10 | 51 |
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