#4731 THE CHANGING HAEMODIALYSIS POPULATION IN A SINGLE UK CENTRE: A POST PANDEMIC PHENOMENON?
Authors: Mckinnell Joanna , Pittman Zoe , Swinscoe Kirsty , Abdulifa Nahedh , Berino Liberty , Selby Nick 
Published: June 2023

Abstract

Background and Aims
Following the Covid-19 pandemic, UK dialysis centres have seen a sharp increase in numbers of patients requiring renal replacement therapy (RRT) particularly haemodialysis (HD). This has resulted in pressures on dialysis capacity and staffing. There may also have been negative effects on other aspects of quality of care, such as a fall in the proportion of patients dialysing via an Arterio-venous fistula (AVF) or worsening anaemia. To study this further, we conducted a retrospective observational study to describe the incident and prevalent HD populations in the post-Covid pandemic period and compare these against pre-pandemic patterns, in a single UK dialysis centre.

Method
We reviewed data on prevalent HD patient numbers across our service. We specifically collected data from all patients commencing HD between January 2021 and December 2022 using electronic medical records. We collected information on time known to renal prior to starting dialysis, clinic data including which types of clinic attended, documentation of pre-dialysis decisions about modality as well as vascular access referrals, vascular access clinics and vascular access surgery as well as haemoglobin (Hb) at first dialysis. We compared figures with published pre-pandemic data from the 23rd annual UK Renal Registry report on data collected to December 2019 for our centre. We defined a planned start to dialysis as patients who were known to renal &gt;90 days. This aligns with the registry definition. We compared proportional data using the chi square test.

Results
Comparing prevalent data in Dec. 2022 with Dec 2019, there was a 17% increase in the prevalent HD population from 298 to 349. The proportion of patients dialysing via an AVF fell from 88% to 80% (p = 0.006). The spread across different types of HD in Dec.2022 remained static at 71% In-Centre HD (72% in Dec 2019), 11% Satellite HD (9% in 2019) and 17% HHD (18% 2019) with overall numbers rising across all HD modalities (p for trend = 0.37). PD numbers also rose from 58 to 71 keeping the total percentage on home therapies stable at 31% in our unit. From Jan. 2021- Dec. 2022 inclusive 147 people commenced HD of whom 115 (78%) had planned starts. This compares to 58 starting HD in 2019 and 79% planned (p = 0.85). There was a significant fall in the proportion of planned start HD patients who commenced dialysis with an AVF/AVG, from 81% in 2019 to 56% in 2021-22 (p = 0.003). Themes emerged n planned starters who did not start HD with an AVF/AVG and are detailed in Figure 1. Median Hb level of planned starts on HD was lower at only 94 for 2021-22 and 99 in 2019. Looking in detail at those missing appointments in clinics, 33% had prior documented evidence of fear of Covid-19. Delays in AVF surgery consisted of delayed and cancelled theatre dates, failed AVF requiring re-do or AVF awaiting further intervention at time of dialysis initiation. In the group with a last minute change in decision sighted reasons included: worsening eyesight, development of dementia in partner, reducing mobility. Others changed their mind after further input from the PD team. Despite attending the Advanced Kidney Clinic (AKC) there were still a number of patients with no decision at all. Cancellation of group sessions for dialysis education persisted in our centre until mid-2022 and may have contributed to reduced timely decision making as well as late modality switches. All those with an early failure of PD (defined as &lt; 90 days) had chosen PD prior to the Covid-19 pandemic with intervening remote visits in AKC.

Conclusion
Following the Covid-19 pandemic, unexpected and unprecedented changes in the HD incident population have been observed, resulting in pressures on dialysis services. In particular, we report an increase in absolute number of dialysis patients, a significant fall in the proportion of patients initiating dialysis with definitive vascular access and a rise in those starting anaemic. This was not related to a change in the proportion of patients with planned starts but may be related to delayed shared decision making as a result of remote consultations and greater delays in vascular access surgery. We have identified a number of areas for service improvement.