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Chronic kidney disease and support provided by home care services: a systematic review Aydede, Sema K; Komenda, Paul; Djurdjev, Ognjenka; Levin, Adeera Jul 18, 2014

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RESEARCH ARTICLEChronic kidney disease antndseare reflected in the demographic profiles of patients with social challenges such as having to cope with several co-Aydede et al. BMC Nephrology 2014, 15:118http://www.biomedcentral.com/1471-2369/15/118ences of receiving care at home [15,16].BC V6Z 2H3, CanadaFull list of author information is available at the end of the articlediseases such as chronic kidney disease (CKD) that arecommon in the elderly. In Canada, over half of the patientsinitiating renal replacement therapy (RRT) in 2009 were65 years of age and older [2]. In Europe, RRT patientsmorbidities, physical disability, cognitive impairment andsocial isolation [4-11]. These medical and social challengesare significant in characterizing the impaired quality of lifein CKD patients [12,13]. Quality of life deteriorates as theseverity of CKD increases [14]. Home care (HC) servicesmay help CKD patients in coping with these challenges,maintaining their independence and fulfilling their prefer-* Correspondence: sema.aydede@ubc.ca1School of Population and Public Health, The University of British Columbiaand Provincial Health Services Authority, 700-1380 Burrard Street, Vancouver,fastest pace ever seen in history [1]. The population trendspart due to an aging population. Support provided through home care services may be useful in attaining a moreefficient and higher quality care for CKD patients.Methods: A systematic review was performed to identify studies examining home care interventions among adultCKD patients incorporating all outcomes. Studies examining home care services as an alternative to acute, post-acuteor hospice care and those for long-term maintenance in patients’ homes were included. Studies with only a hometraining intervention and those without an applied research component were excluded.Results: Seventeen studies (10 cohort, 4 non-comparative, 2 cross-sectional, 1 randomized) examined the supportprovided by home care services in 15,058 CKD patients. Fourteen studies included peritoneal dialysis (PD), twoincorporated hemodialysis (HD) and one included both PD and HD patients in their treatment groups. Sixteen studiesfocused on the dialysis phase of care in their study samples and one study included information from both thedialysis and pre-dialysis phases of care. Study settings included nine single hospital/dialysis centers and three regional/metropolitan areas and five were at the national level. Studies primarily focused on nurse assisted home care patientsand mostly examined PD related clinical outcomes. In PD studies with comparators, peritonitis risks and techniquesurvival rates were similar across home care assisted patients and comparators. The risk of mortality, however, washigher for home care assisted PD patients. While most studies adjusted for age and comorbidities, information aboutmultidimensional prognostic indices that take into account physical, psychological, cognitive, functional and socialfactors among CKD patients was not easily available.Conclusions: Most studies focused on nurse assisted home care patients on dialysis. The majority were single sitestudies incorporating small patient populations. There are gaps in the literature regarding the utility of providing homecare to CKD patients and the impact this has on healthcare resources.Keywords: Chronic kidney disease, Dialysis, Home care servicesBackgroundThe world population is aging and the segment of globalpopulation 60 years of age and over is increasing at the65 years of age and older had the highest rate of increasein prevalence over the 1992–2005 period [3].CKD populations, especially elderly end-stage renal dis-ease (ESRD) patients, are faced with multiple medical andhome care services: a sysSema K Aydede1*, Paul Komenda2, Ognjenka Djurdjev3 aAbstractBackground: Chronic diseases, such as chronic kidney di© 2014 Aydede et al.; licensee BioMed CentraCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Open Accessd support provided byematic reviewAdeera Levin4ase (CKD), are growing in incidence and prevalence, inl Ltd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Aydede et al. BMC Nephrology 2014, 15:118 Page 2 of 18http://www.biomedcentral.com/1471-2369/15/118Current emphasis on active aging and independence rep-resent a unique opportunity to examine HC services thatare utilized to varying degrees by different patient groupsbut are considered beneficial especially in chronic condi-tions [17]. In the case of non-ESRD CKD, the utilization ofHC may vary based on patient’s age and comorbidities and,in the case of ESRD, it may vary based on the severity ofillness and therapy type. HC services may help in support-ing ESRD patients who have chosen conservative care. Theindependent treatment modalities for ESRD (peritonealdialysis, PD, and home hemodialysis, HHD), emphasizedas viable alternatives to facility-based treatment modalitiesover the last decade, are less costly to direct service pro-viders, with equivalent or superior patient outcomes andquality of life [18-21]. Patients with ESRD, who are on PDor HHD, however, may utilize more HC services comparedto those who are on a facility-based hemodialysis (HD),partially offsetting cost saving [22,23]. On the other hand,the intensity of HC services received may reduce thenumber of hospitalizations and subsequent health sys-tem costs [24-26] regardless of the stage of CKD andthe type of therapy for ESRD.In general, HC services provide support to patients andhelp them with the daily management of their diseases intheir communities. However, a proper characterizationand a systematic evaluation of these services within a highrisk, resource intense group of patients such as those withCKD have not been undertaken. This systematic review(SR) provides a rigorous account of research evidence onHC use among those with CKD.MethodsEligibility criteriaStudies about adult patients with any CKD severity leveland a HC intervention regarding services provided inpatients’ homes were eligible. Our SR was not restrictedto studies that incorporated a comparison group. Studieswith interventions related to the market place and work-ing conditions of HC professionals or organizational un-derpinnings of HC organizations were excluded.In the case of RRT, assisted PD patients could get helpfrom a family member, a friend or a HC worker. In thisSR, studies that focused on assisted PD in general with-out providing subgroup results for HC assisted PD pa-tients [27-32] and those that examined home visits forreasons other than direct HC provision [33-36] were ex-cluded. Unlike assisted PD, HHD is rarely available in anassisted format. One recent study that focused on thefeasibility of nocturnal assisted HHD did not providesubgroup results for HC assisted HHD patients and,therefore, was not included in our SR [37].In the case of palliative care, support services for CKDpatients could be provided in their home or at a hospice.This study focused on home-based end-of-life care.Studies that examined palliative care without providinginformation about the specific services patients receivedin their community and those that did not separately re-port on subgroups of patients who received home-basedsupport services [38-42] were excluded from our SR.The primary outcomes included hospitalizations, admis-sions to institutional settings, length of stay on independ-ent dialysis modalities for ESRD patients, and outcomesspecific to treatment type. As secondary outcomes, mor-tality, medication management, patient satisfaction, care-giver satisfaction, physical and psychological well-being,health status and quality of life were considered. Studieswere not excluded based on outcomes studied.In general, all types of studies including experimentaland observational studies were included. The studiesthat did not contain an empirical component and thosewith only training/educational and referral/recommen-dations types of interventions were excluded.Given the diversity of HC services and resource consid-erations, we concentrated on studies published in English.To balance this limitation, a comprehensive literaturesearch was undertaken. The date range was 1990 (i.e., theearly stages of profound changes in healthcare systemsthat started with shifts away from acute care settings to-wards home and community care [43]) to present.DefinitionsCKD was conceptualized as consisting of five stages fol-lowing the Kidney Disease Outcomes Quality Initiative’sdefinition accepted during the Kidney Disease: ImprovingGlobal Outcomes (KDIGO) conference [44]. The defin-ition accepted during the KDIGO conference suggests thatCKD could also be classified by treatment type: kidneytransplant recipient, CKD independent of dialysis andCKD on dialysis. These classifications guided the develop-ment phase of our SR.The Federal/Provincial/Territorial Working Group onHome Care’s definition, as reported by Health Canada,emphasizes the manner with which HC helps patients:“An array of services which enables clients, incapacitatedin whole or part, to live at home, often with the affect ofpreventing, delaying or substituting for long-term or acutecare alternatives” [45]. The Canadian Home Care Associa-tion’s definition focuses on the breadth of services covered:“an array of services, provided in the home and commu-nity setting, that encompasses health promotion and teach-ing, curative intervention, end-of-life care, rehabilitation,support and maintenance, social adaptation and inte-gration and support for the family caregiver” [46]. Initially,HC conceptualization for this SR was guided by thesedefinitions. These conceptualizations were further refinedduring the course of this study as we attempted tostandardize terminology for our SR based on HC servicescovered in the included studies.HTA and NHS EED), ACP Journal Club and Web ofconducted by a University of British Columbia librarian,summarized using a pre-tested data extraction form andAydede et al. BMC Nephrology 2014, 15:118 Page 3 of 18http://www.biomedcentral.com/1471-2369/15/118was evaluated using the Agency for Healthcare Researchand Quality risk of bias and confounding form developedfor observational studies [47].AnalysisDue to the heterogeneity of patient populations consid-ered, interventions examined and health outcomes re-ported in the studies included in our SR, a meta-analysiswas not possible. We performed a narrative summary ofstudies focusing mainly on key outcomes of importanceto the CKD community.ResultsStudy selectionA total of 17 studies were identified for inclusion in theSR. The searches of electronic databases provided a totalof 4354 citations (Figure 1) with 185 additional citationsidentified through hand-searches and author consulta-tions. After adjustments for duplicates and title and ab-were completed on May 24, 2012. Hand searches, com-pleted on September 20, 2013, were coupled with consulta-tions with experts in the field.Study selectionWe followed a layered approach in study selection. An ini-tial elimination of irrelevant studies was carried out bystudy assistants independently based on title and abstractreviews using a pre-tested selection form. An author (SKA)checked the initial selection and reviewed the completetexts of potentially relevant studies. The remaining manu-scripts were reviewed in full by two additional authors in-dependently (AL and PK). Disagreements were resolvedafter discussions among authors. Each selected study wasScience (final search for MEDLINE is incorporated in theAppendix; final searches for other databases are availablefrom the corresponding author). The web sites includedWorld Health Organization, Health Canada, CanadianHomecare Association, Canadian Health Research Collec-tion and the health departments of Canadian provinces andterritories. The electronic database and web site searches,Information sourcesStudies were identified through electronic databases, web sites,hand searches and consultations with experts in thefield. Electronic databases included MEDLINE, EMBASE,CINAHL, PsycINFO, EconLit, Cochrane CENTRAL, CochraneMethodology Register, Cochrane Database of SystematicReviews, Centre for Reviews and Dissemination (DARE,stract screening, a total of 521 full text articles wereassessed and 17 were eligible for inclusion.Study characteristics and patient populationsOf the 17 studies included in this study (overview of studycharacteristics in Table 1 and detail on patient popula-tions, HC interventions and outcomes in Table 2), 14focused on the impact HC has on PD patients. Ten ofthe PD studies were cohort studies [48-57], three werenon-comparative [58-60] and one used cross sectionalstudy design [61]. Five national level PD cohort studies[48,51,52,55,56] used information from the French Lan-guage Peritoneal Dialysis Registry (RDPLF). Two of theseRDPLF studies [51,52] used the same time period but ap-plied different exclusion criteria based on the focus ofthe studies. Two PD cohort studies [53,54] relied on datafrom regional dialysis units. The remaining three PD co-hort studies [49,50,57] and all of the non-comparative andcross sectional PD studies [58-61] used data from a singlehospital/dialysis unit. Of the 14 PD studies, 6 were fromFrance [48,50-52,55,56], 3 from Canada [53,54,58], 2 fromthe United States of America (USA) [60,61] and one eachfrom China [57], Taiwan [49] and Brazil [59].Of the 17 studies included in this study, 2 studies exam-ined the impact HC has on HD patients. One of thesestudies was a randomized trial [62] conducted in an Iranianhospital and the second one was a non-comparative studythat used information from citywide dialysis units in theUSA [63].In contrast to the general trend of studies included inthis SR where the focus was exclusively on the dialysisphase of care for patients, one study [64] included in-formation from both the dialysis and pre-dialysis phasesof care for PD and HD patients. This study exploredthe impact HC has on patients in one hospital in theUnited Kingdom.The studies included in this SR examined HC in a totalof 15,058 patients (Table 2). Patients on PD treatment(with a total of 14,954 patients) constituted the dialysispopulation that was most frequently studied. While moststudies focused on general dialysis populations, two PDstudies [58,60] and one HD study [63] examined HC inspecial dialysis populations that had severe disability, ter-minal illness or complex comorbid conditions.Of the 17 studies included in this review, 3 focused onelderly patients [48,49,53] with average age of the studysamples ranging from 73 years [49] to 82 years [48]. Inthe remaining studies with pertinent information, aver-age age ranged from 55 years [56,61] to 69 years [63].The PD studies with comparators and pertinent infor-mation revealed that HC assisted PD patients had ahigher average age ranging from 71 years [57] to 83 years[48] when compared to the overall age of study samples.Home care interventionHC interventions primarily focused on the assistance pro-vided during dialysis treatment (Table 2). The two studies1Aydede et al. BMC Nephrology 2014, 15:118 Page 4 of 18http://www.biomedcentral.com/1471-2369/15/118n 4354 titles identified viathat examined HC interventions for HD patients [62,63]and most of the HC assisted PD studies [48,50-53,55,56,58,60] focused on assistance dialysis patients receivedfrom a nurse. Two of the remaining studies [61,64] con-sidered the effects of HC teams and the rest focused onIdentificatioScreeningEligibilityIncludedelectronic and web site  t3782 titles after duplic3782 abstractsscreened 521 full-text articlesassessed for eligibili17 studies included ithe systematic reviewFigure 1 Chronic kidney disease & home care systematic review PRIS85 additional titles identifiedassistance received from either a home-assistant where abackground in healthcare was not necessary [49,57], anurse assistant [59] or a nurse or a healthcare aid [54].There are several factors, such as the severity of illness,the scope of HC provision and the requirements of dialysishrough other sources ates removed3261 abstracts excludedty 504 full-text articles excluded:• 26 no chronic kidney disease patients • 7 had subjects younger than19 years of age • 245 no original data• 166 no home care patients• 41no separate analysis forhome care patients • 19 home visit for reasonsother than providing home care n MA flow diagram.datAydede et al. BMC Nephrology 2014, 15:118 Page 5 of 18http://www.biomedcentral.com/1471-2369/15/118Table 1 Overview of study characteristicsStudy Type of study Setting,Peritoneal dialysistechnique used, that will influence the characteristics ofa HC intervention. While patients on continuous cyc-ling PD (CCPD) will mostly require two visits per day,those on continuous ambulatory PD (CAPD) may re-quire one to four visits based on the severity of theirdisability [56,58]. The time that a HC worker spends atBrunier et al. [58] Non-Comparative (Case Series) • Hospital• SunnybrooCastrale et al. [48] Retrospective Cohort • National• French PeriFranco et al. [59] Non-Comparative (Case Series) • Clinic• GAMEN ReHsieh et al. [49] Prospective Cohort • Hospital• Chang GunLobbedez et al. [50] Retrospective Cohort • Hospital• Academic HLobbedez et al. [51] Retrospective Cohort • National• French PerLobbedez et al. [52] Retrospective Cohort • National• French PerOliver et al. [53] Prospective Cohort • Regional D• SunnybrooOliver et al. [54] Prospective Cohort • 4 Regional• SunnybrooHSC, ManitoPonferrada et al. [61] Cross Sectional (Survey) • Dialysis Un• Dialysis CliVerger et al. [55] Retrospective Cohort • National• French PeriVerger et al. [56] Retrospective Cohort • National• French PeriWadhwa et al. [60] Non-Comparative (Case Series) • Hospital• Division ofYork (JanuarXu et al. [57] Prospective Cohort • Hospital• Peking UniHemodialysisAgraharkar et al. [63] Non-Comparative (Case Series) • Citywide• Dialysis cenBabamohammadi et al. [62] Randomized controlled trial • Hospital• FatemyehPre-dialysis & dialysisWilde et al. [64] Cross Sectional (Survey) • Hospital• Leicester Ga source & data period Countrya CAPD patient’s home is dependent on the CAPD systemused. PD exchange help for a patient on an ultravioletnon-disconnect CAPD system will usually require lesstime (about 10–15 minutes) compared to the time (about30–45 minutes) needed for a patient on a double-bagdisconnect CAPD system [55].Canadak Health Science Centre (November 1993 - May 1995)Francetoneal Dialysis Registry Data (January 2000 - December 2007)Brazilnal Clinic (January 2003- July 2009)Taiwang Memorial (January 2000 - December 2009)Franceospital of Basse-Normandie (1 January 1998–31 December 2003)Franceitoneal Dialysis Registry Data (1 January 2002 – 1 June 2011)Franceitoneal Dialysis Registry Data (1 January 2002 – 1 June 2011)ialysis Center Canadak Health Science Centre (1 January 2004–25 May 2006)Dialysis Centers Canadak Health Science Centre (HSC), Halton Healthcare, Londonba Renal Program (January 2004 - January 2009)it USAnic Inc (Data period not reported)Francetoneal Dialysis Registry Data (1 January 1995–1 January 2006)Francetoneal Dialysis Registry Data (1 January 2000 – 1 January 2005)USANephrology and Hypertension - State University of Newy 1989 - December 1992)Chinaversity First Hospital (July 2002 - April 2010)USAters in the greater Houston area (1995–1998)IranHospital (Data period not reported)UKeneral Hospital (Data period not reported)Table 2 Patient population, intervention type and major findings of studiesStudy Number of patients Mean age Type of home care intervention Major findingsPeritoneal dialysisBrunier et al. [58] • 18 HC assisted PDα • 61 • HCβ (Nurse) assisted PD: Publicly funded programwhere nurses visit homes for PD exchanges andclinical and social supportPeritonitis Rate:• One episode of peritonitis per 33.8patients-months (excluding 1 lowwhite blood and 1 AIDS patient); ifincluded, one episode of peritonitisper 20.1 patients-months• CAPDγ required 1–4 visits / day based on severityof disabilityHospitalization Rate:• One hospital admission per 15.3patient-months (excluding 5 palliativecare patients)• CCPDδ required 2 visits / dayCosts:• Reporting on 3 years of experience• Annual costs were $27,263 for homeCAPD, $29,763 for home CCPD and$29,915 for HDεCastrale et al. [48] • 1232 HC assisted PD • 83 (HC assisted PD) • HC (Nurse) assisted PD: Publicly funded homevisits by private sector nurses for assisted PDPeritonitis Rate:• Compared to self care PD, HC(nurse) assisted PD had similar risksof peritonitis rates (Bivariate results)• 87 Family assisted PD • 81 (Family assisted PD)• Study end point allowed for at least 2 years offollow-up for patients who are on PD continuously(Frequency of visits not reported)Patient Survival:• Compared to self care PD, HC(nurse) assisted PD was associatedwith a higher risk of mortality(RHζ = 2.35)• 294 Self care PD • 80 (Self care PD)Technique Survival:* Elderly• Compared to self care PD, HC (nurse)assisted PD had similar risks oftechnique failure (=transfer to HD)Franco et al. [59] • 30 HC assisted PD • 72 (Median) • HC (Nurse Assistant) assisted PD: Home visits bynurse assistants for assisted PDPeritonitis Rate:• One episode of peritonitis per 37patient-months• Study end point allowed for at least 16 monthsof follow-up for patients who are on PDcontinuously (Frequency of visits not reported) Patient Survival:• Patient survival was 60% at 12months, 23% at 24 month, 3% at48 months• Each nurse assistant was responsible for 4 patientsAydedeetal.BMCNephrology2014,15:118Page6of18http://www.biomedcentral.com/1471-2369/15/118Table 2 Patient population, intervention type and major findings of studies (Continued)Hsieh et al. [49] • 32 HC assisted PD • 76 (HC assisted PD) • HC (Home Assistant) assisted PD: Home assistants(a background in healthcare was not required)paid by the family assisted with PD.Peritonitis Rate:• Peritonitis rates of 1 episode per24 (HC-home assistant-assisted PD),37 (family assisted PD) and 39 (self PD)patient months were not significantlydifferent• 44 Family assisted PD • 74 (Family assisted PD)• HC assisted PD patients followed for 93 to1832 days (Frequency of visits not reported)• Probability of a 12 month peritonitis-freeperiods of 62.5% (HC-homeassistant-assisted PD), 75.0% (familyassisted PD) and 80.8% (self PD) werenot significantly different• 26 Self care PD • 69 (Self care PD)Patient Survival:* Elderly• Peritonitis-related deaths of 13.8% (HC-homeassistant-assisted PD), 8.0% (family assisted PD)and 8.0% (self PD) were not significantly differentTechnique Survival:• Following peritonitis, technique failuresof 34.5% (HC-home assistant-assisted PD),16.0% (family assisted PD) and 16.0%(self PD) were not significantly differentLobbedez et al. [50] • 36 HC assisted PD • 74 (HC assisted PD) • HC (Nurse) assisted PD: Publicly funded homevisits by private sector nurses for assisted PDPD Eligibility/Utilization/Uptake:• HC (nurse) assisted PD enables increaseduse of PD in incident dialysis patients• 61 Self care PD • 52 (Self care PD)• HC assisted PD patients followed for 0.5 to51 months (Frequency of visits not reported)Peritonitis Rate:• HC (nurse) assisted PD patients: Actuarialsurvival free of peritonitis was 72% at6 months, 50% at 12 months• 36 Satellite HD • 47 (Satellite HD)Hospitalization Rate:• 106 In-center HD • 67 (In-center HD)• HC (nurse) assisted PD patients:• Actuarial survival free of hospitalization46% at 6 months, 21% at 12 months• Hospitalization rate was 0.4 admissions/patient/monthTechnique Survival:• HC (nurse) assisted PD patients: Techniquesurvival 85% at 6 months, 58% at 12 monthsCharlson Comorbidity Index:• Charlson Comorbidity Index higher for HC(nurse) assisted PD (7.0) when compared toself care PD (4.3) and similar whencompared to in-center HD (7.7)Aydedeetal.BMCNephrology2014,15:118Page7of18http://www.biomedcentral.com/1471-2369/15/118Table 2 Patient population, intervention type and major findings of studies (Continued)Lobbedez et al. [51] • 4230 HC assisted PD • 79 (Median, HC assisted PD) • HC (Nurse) assisted PD: Publicly funded homevisits by private sector nurses for assisted PDPatient Survival:• Compared to self care PD, HC (nurse) assistedPD was associated with a higher risk of mortality(cs-RHη = 4.52)• 1056 Family PD • 74 (Median, Family assistedPD) • Study end point allowed for at least 5 monthsof follow-up for patients who are on PDcontinuously (Frequency of visits not reported)• Compared to self care PD + family assisted PD,HC (nurse) assisted PD was associated with ahigher risk of mortality (cs-RH = 2.18)• 4515 Self care PD• 56 (Median, Self care PD)• Interquartile range of PD duration 7.78 to29.70 monthsTechnique Survival:• Compared to self care PD, HC (nurse) assistedPD was associated with a lower risk of techniquefailure (=transfer to HD, cs-RH = 0.84, sd-RHθ = 0.72)• Compared to self care PD+ family assisted PD, HC (nurse)assisted PD was associated with a lower risk of techniquefailure (=transfer to HD, cs-RH = 0.85, sd-RH = 0.72)Renal Transplantation:• Compared to self care PD, HC (nurse) assisted PDwas associated with a lower risk of renaltransplantation (cs-RH = 0.04)• Compared to self care PD + family assisted PD, HC(nurse) assisted PD was associated with a lower riskof renal transplantation (cs-RH = 0.16)Renal Recovery:• Compared to self care PD, HC (nurse) assisted PDwas associated with a similar risk of renal recovery(Bivariate results)• Compared to self care PD+ family assisted PD, HC (nurse)assisted PD was associated with a similar risk of renal recoveryLobbedez et al. [52] • 3689 HC assisted PD • 71 (Median, Planned PDStart)• HC (Nurse) assisted PD: Publicly funded homevisits by private sector nurses for assisted PDPeritonitis Rate:• Compared to self care PD, HC (nurse) assisted PD wasassociated with a lower risk of peritonitis (sd-RH = 0.81)• 902 Family PD• 69 (Median, Sub-optimal PDStart)• Study end point allowed for at least 5 months offollow-up for patients who are on PD continuously(Frequency of visits not reported) Patient Survival:• Compared to self care PD, HC (nurse) assisted PD wasassociated with a higher risk of mortality (sd-RH = 6.30)• 3891 Self care PD• Interquartile range of PD duration 8.08 to29.99 monthsTechnique Survival:• Compared to self care PD, HC (nurse) assisted PD wasassociated with a lower risk of technique failure (=transferto HD, sd-RH = 0.67)*Additional exclusions comparedo Lobbedez et al., 2012 to focuson sub-optimal PD startsRenal Transplantation:• Compared to self care PD, HC (nurse) assisted PD wasassociated with a lower risk of renal transplantation(sd-RH = 0.03) (Bivariate results)Aydedeetal.BMCNephrology2014,15:118Page8of18http://www.biomedcentral.com/1471-2369/15/118Table 2 Patient population, intervention type and major findings of studies (Continued)Oliver et al. [53] • 22 HC assisted PD • 76 (Median, HC assisted PD) • HC (Nurse) assisted PD: Publicly funded programwhere nurses visit homes for PD exchanges andclinical and social supportPD Eligibility/Utilization/Uptake:• More elderly patients were considered eligible for PD(ORι = 2.6) if they lived in a HC support region than ifthey did not• 4 Self care PD • 76 (Median, OtherModalities)• First year of dialysis, HC assisted PD patientsreceived, on average, 5.8 visits / weekHospitalization Rate & Days:• Hospitalization rate was not significantly differentbetween HC (nurse) assisted PD (1.4 per patient-year)and other modalities (1.0 per patient-year)• 16 In-center HD*Elderly• HC assisted PD patients offered 2 visits / day7 days a week• Hospital days were not significantly different betweenHC (nurse) assisted PD (23.5 per patient-year) and othermodalities (13.1 per patient-year)• Mean follow-up for HC assisted PD patientswere 413 daysPatient Survival:• Mortality was not significantly different between HC(nurse) assisted PD (0.12 per patient-year) andother modalities (0.18 per patient-year)Technique Survival:• Modality changes were not significantly differentbetween HC (nurse) assisted PD (0.04 per patient-year)and other modalities (0.19 per patient-year)Oliver et al. [54] • 56 HC assisted PD • 66 (Overall) • HC (Nurse or Healthcare Aid) assisted PD:Publicly funded program where nurses orhealthcare aids visit homes for assisted PDPD Eligibility/Utilization/Uptake:• Even when HC (nurse or healthcare aid) assisted PD isavailable, family support remains to be an importantdriver of PD utilization.• 8 Family and HC assisted PD• Maximum 2 nurse or healthcare aid visits/day• Among patients with barriers to PD who live in areaswith HC assisted PD availability, PD utilization was higher(39%) among those who had family support comparedto those without family support (23%)• 26 Family assisted PD• Mean (median) follow-up for PD patients were521 (376) days• 1 Friend assisted PD• 56 Self care PDPonferrada et al. [61] • 36 HC assisted PD • 55 • HC (Team) assisted PD: Home visits by homecare team (nurse, dietician & social worker) forassisted PD and patient assessmentsCritical Elements of Home Visits:• Dialysis programs should retain the option of makinghome visits to home dialysis patients• Reporting on evaluation over a 18-month period• To evaluate internal policy and identify criticalelements of a home visit• Study recommendations: One routine visit fornew patients and additional non-routine visitsonly if there are significant problems• A visit took approximately 4 hoursAydedeetal.BMCNephrology2014,15:118Page9of18http://www.biomedcentral.com/1471-2369/15/118Table 2 Patient population, intervention type and major findings of studies (Continued)Verger et al. [55] • 5284 HC assisted PD • 66 (Overall) • HC (Nurse) assisted PD: Publicly funded homevisits by private sector nurses for assisted PDPD Eligibility/Utilization/Uptake:• Provides a description of the PD population• 822 Family assisted PD• Nurse time at patient’s home for: a) non-disconnectCAPD ultraviolet system between 10–15 minutes,and b) double-bag disconnect CAPD systembetween 30–45 minutes (Frequency of visitsnot reported)• Over the decade studied, 45% of all incident PD patientsreceived HC (nurse) assisted PD and 87% of incident PDpatients over 90 years of age received HC (nurse) assisted PD• 8285 Self care PDCharlson Comorbidity Index:• Among prevalent PD patients, Charlson comorbidity index,on average, was 7.6 for HC (nurse) assisted PD, 6.6 for familyassisted PD and 4.8 for self care PD• 352 Other / Undefined PDVerger et al. [56] • 232 HC assisted PD • 73 (HC assisted PD) • HC (Nurse) assisted PD: Publicly funded homevisits by private sector nurses for assisted PDPeritonitis Rate:• The probability of being peritonitis free at 24 monthsbetter for family assisted PD (76.7%) compared to HC(nurse) assisted PD (41.2%) when nurse visits from dialysiscenters are not considered• 127 Family assisted PD • 65 (Family assisted PD)• Study end point allowed for at least 13 monthsof follow-up for patients who are on PD continuously• The probability of being peritonitis free at 24 monthssimilar between family assisted PD (57.7%) and HC (nurse)assisted PD (60.7%) when nurse visits from dialysis centersare considered• 1265 Self care PD • 51 (Self care PD)• 1–2 nurse visits / day• For HC (nurse) assisted PD, the probability of beingperitonitis free better for those affiliated with dialysiscenters with nurse visits*Automated PD patients only• For family assisted PD, the probability of being peritonitisfree similar across centers with and without nurse visitsWadhwa et al. [60] • 21 HC assisted PD • 62 • HC (Nurse) assisted PD: Home visits by nurses forassisted PD and clinical supportPeritonitis Rate:• One episode of peritonitis per 13 patient-months• Mean number of nursing hours per day was 13(Frequency of visits not reported) Hospitalization Rate & Days:• One hospital admission per 6 patient-months• Mean hospitalization days of 9 per admissionXu et al. [57] • 36 HC assisted PD • 71 (HC assisted PD) • HC (Home Assistant) assisted PD: Home assistants(a healthcare background was not required) paidby the family assisted with PDPeritonitis Rate:• First episode of peritonitis was not significantly differentbetween HC (home assistant) assisted PD and familyassisted PD• 86 Family assisted PD • 66 (Family assisted PD)• PD patients followed for 1 to 88 months(Frequency of visits not reported)Patient Survival:• Compared to family assisted PD, HC (home assistant) assistedPD was associated with higher risk of mortality (HR = 2.14)• 191 Self care PD • 55 (Self care PD)Technique Survival:• Technique survival was not significantly different betweenHC (home assistant) assisted PD (69.8 months) and familyassisted PD (74.8 months)Aydedeetal.BMCNephrology2014,15:118Page10of18http://www.biomedcentral.com/1471-2369/15/118Table 2 Patient population, intervention type and major findings of studies (Continued)HemodialysisAgraharkar et al. [63] • 28 HC assisted HD • 69 • HC (Nurse) Assisted HD: Home visit by registerednurse for dialysis and clinical supportHospital Days:• Mean hospitalization days of 9.43+/−1.83• Nephrologists also made home visits Costs:• HD patients followed for 2 to 71 weeks • Weekly ongoing costs of HC(nurse) assisted HD were$1200, in-center HD with ambulance transportation were$2640 and in-hospital dialysis were $5241• Frequency of visits determined by the nephrologistupon patient’s discharge from the hospitalBabamohammadiet al. [62]• 19 HC assisted HD • 56 (HC assisted HD) • HC (Nurse) Assisted HD: Visits every week beforeHD schedule for clinical support and retraining19 Clinical Outcomes:• 15 out of the 19 items studied improved for home caregroup (weight gain, nausea, vomiting, headache, bonepain, weakness and fatigue, and itching decreasedand general condition and levels of BUN, creatinine,potassium and phosphorus of the blood improvedsignificantly. Changes in the mean values of bloodpressure, pulse, temperature, sodium and calciumand hematocrit were not significant)• 18 HD without HC • 58 (HD without HC)• Mean follow-up for HC assisted HD patients were27.1 months• 4 visits / monthPre-dialysis & DialysisWilde et al. [64] • 57 HC assisted PD or HD • Not described • HC (Team): Home care team (3 nurses & 1 renalcare assistant) visits during pre-dialysis and dialysisphase of care for PD and HD patientsSatisfaction with Home Care:• Overall satisfaction with home care program: a) pre-dialysisphase of care− 76% very satisfied, 20% partly satisfied and b)dialysis phase of care− 80% very satisfied, 20% partly satisfied• Visits until transplantation, switch to hospital-baseddialysis or death (Frequency of visits not reported)αPD: Peritoneal Dialysis.βHC: Home Care.γCAPD: Continuous Ambulatory Peritoneal Dialysis.δCCPD: Continuous Cycling Peritoneal Dialysis.εHD: Hemodialysis.*Elderly: Identifies studies focusing on patients at least 65 years of age and older.ζRH: Relative Hazard.ηcs-HR: Cause-Specific RH.θsd-RH: Fine and Gray Sub-Distribution RH.ιOR: Odds ratio.Aydedeetal.BMCNephrology2014,15:118Page11of18http://www.biomedcentral.com/1471-2369/15/118Table 3 Risk of bias and confoundingRisk of bias and confoundingQ1: Do the inclusion/exclusion criteria remain identical across the comparison groups (the individuals) of the study?PeritonealDialysisYes Castrale [48], Franco [59], Hsieh [49], Lobbedez [51,52], Verger [55,56], Xu [57]Partially Brunier [58], Lobbedez [50], Oliver [53,54], Ponferrada [61], Wadhwa [60]Hemodialysis Yes Agraharkar [63], Babamohammadi [62]Pre-dialysis &DialysisNo Wilde [64]Q2: Does the strategy for recruiting participants into the study remain identical across groups (individuals)?PeritonealDialysisYes Brunier [58], Castrale [48], Franco [59], Hsieh [49], Lobbedez [50-52], Oliver [53,54], Ponferrada [61], Verger [55,56],Wadhwa [60], Xu [57]Hemodialysis Yes Agraharkar [63], Babamohammadi [62]Pre-dialysis &DialysisYes Wilde [64]Q3: Is the selection of the comparison group appropriate, after taking into account feasibility and ethical considerations?PeritonealDialysisYes Castrale [48], Hsieh [49], Lobbedez [50-52], Oliver [53,54], Verger [55,56], Xu [57]Not Applicable Brunier [58], Franco [59], Ponferrada [61], Wadhwa [60]Hemodialysis Yes Babamohammadi [62]Not Applicable Agraharkar [63]Pre-dialysis &DialysisNot Applicable Wilde [64]Q4: Does the study account for important variations in the execution of the study?PeritonealDialysisYes Castrale [48], Franco [59], Lobbedez [51,52], Oliver [53,54], Ponferrada [61], Verger [56]Partially Brunier [58], Hsieh [49], Lobbedez [50], Wadhwa [60], Xu [57]Not Applicable Verger [55]Hemodialysis Yes Babamohammadi [62]Partially Agraharkar [63]Pre-dialysis &DialysisNo Wilde [64]Q5: Were valid and reliable measures, implemented consistently across all study participants used to assess inclusion/exclusion criteria,intervention/exposure outcomes, participant benefits and harms, and potential confounders?PeritonealDialysisYes Brunier [58], Castrale [48], Franco [59], Hsieh [49], Lobbedez [50-52], Oliver [53,54], Ponferrada [61], Verger [55,56],Wadhwa [60], Xu [57]Hemodialysis Yes Agraharkar [63], Babamohammadi [62]Pre-dialysis &DialysisYes Wilde [64]Q6: Was the length of follow-up identical across study groups or remedied through analysis?PeritonealDialysisYes Castrale [48], Lobbedez [51,52], Xu [57]No Hsieh [49], Lobbedez [50], Oliver [53], Verger [56]Not Applicable Brunier [58], Franco [59], Oliver [54], Ponferrada [61], Verger [55], Wadhwa [60]Hemodialysis Yes Babamohammadi [62]Not Applicable Agraharkar [63]Pre-dialysis &DialysisNot Applicable Wilde [64]Q7: In cases of high loss to follow-up (or differential loss to follow-up), was the impact assessed (e.g., through sensitivity analysis or otheradjustment method)?PeritonealDialysisYes Lobbedez [51,52]No Brunier [58], Oliver [53], Wadhwa [60]Not Applicable Oliver [54], Ponferrada [61], Verger [55]Aydede et al. BMC Nephrology 2014, 15:118 Page 12 of 18http://www.biomedcentral.com/1471-2369/15/118ob]?, HAydede et al. BMC Nephrology 2014, 15:118 Page 13 of 18http://www.biomedcentral.com/1471-2369/15/118Table 3 Risk of bias and confounding (Continued)CannotDetermineCastrale [48], Franco [59], Hsieh [49], LHemodialysis CannotDetermineAgraharkar [63], Babamohammadi [62Pre-dialysis &DialysisNo Wilde [64]Q8: Are all important primary outcomes accounted for in the resultsPeritonealDialysisYes Brunier [58], Castrale [48], Franco [59]Wadhwa [60], Xu [57]Hemodialysis Yes Babamohammadi [62]Based on studies with pertinent information, patientsin Canada [53,54] were offered 14 visits per week forhelp with their PD exchanges and for the provision ofclinical and social support. These patients received, onaverage, 5.8 visits per week during the first year of theirdialysis [53]. In a USA program, a routine visit to a newPD patient was carried out to ensure proper installationof the cycler for an effective dialysis and non-routinevisits were made only on an as-needed basis [61]. In thisprogram, a visit took approximately four hours. AnotherUSA program focused on ESRD patients with multiplemedical and social problems [60]. In this program, a visitto help patients with their PD exchanges and to provideclinical and social support took, on average, 13 hours. InPartially Agraharkar [63]Pre-dialysis &DialysisYes Wilde [64]Q9: Are results believable taking study limitations into consideration?PeritonealDialysisYes Brunier [58], Castrale [48], Franco [59], HWadhwa [60], Xu [57]Hemodialysis Yes Agraharkar [63], Babamohammadi [62]Pre-dialysis &DialysisPartially Wilde [64]Q10: Did the study attempt to balance the allocation between the groupropensity scores)?PeritonealDialysisYes Castrale [48], Lobbedez [51,52], Oliver [5No Hsieh [49], Lobbedez [50], Oliver [54], VeNot Applicable Brunier [58], Franco [59], Ponferrada [61]Hemodialysis Yes Babamohammadi [62]Not Applicable Agraharkar [63]Pre-dialysis &DialysisNot Applicable Wilde [64]Q11: Were important confounding variables taken into account in theinteraction terms, multivariate analysis, or other statistical adjustmentPeritonealDialysisPartially Castrale [48], Franco [59], Hsieh [49], LobNo Brunier [58], Lobbedez [50], Oliver [54], PHemodialysis Yes Babamohammadi [62]No Agraharkar [63]Pre-dialysis &DialysisNo Wilde [64]bedez [50], Verger [56], Xu [57]sieh [49], Lobbedez [50-52], Oliver [53,54], Ponferrada [61], Verger [55,56],a HD study from Iran, the HC intervention was designedto conduct one visit per week before the HD schedulefor clinical support and retraining [62].OutcomesPeritoneal dialysisWhile most of the PD studies focused on outcomes re-lated to PD treatment (Table 2), a few provided insightsinto how the availability of assisted PD offers a choice topatients who are unable to perform their RRT independ-ently. A description of the PD population in France [55],where healthcare system supports nurse assisted PD, re-vealed that 45% of all PD patients and 87% of those over90 years of age were assisted by a nurse. Studies havesieh [49], Lobbedez [50-52], Oliver [53,54], Ponferrada [61], Verger [55,56],ps or match groups (e.g., through stratification, matching,3], Verger [56], Xu [57]rger [55], Wadhwa [60]design and/or analysis (e.g., through matching, stratification,such as instrumental variables)?bedez [51,52], Oliver [53], Verger [56], Xu [57]onferrada [61], Verger [55], Wadhwa [60]Aydede et al. BMC Nephrology 2014, 15:118 Page 14 of 18http://www.biomedcentral.com/1471-2369/15/118shown that the availability of nurse assisted PD increasesthe eligibility for PD among elderly patients [53] and im-proved the uptake of PD in general [50]. One study [54]emphasized the importance of the availability of familyassistance for PD utilization even in regions where HCassisted PD is available.In PD studies with comparators, outcomes such asperitonitis rate and technique and patient survival con-stituted the main areas of focus. In general PD popula-tions, studies using information from RDPLF concludedthat technique failure/transfer to HD was lower amongHC (nurse) assisted PD patients when compared to selfcare PD patients only [51,52] and to self care PD andfamily assisted PD patients as a group [51]. Anotherstudy in general PD populations [57], where home-assistants who were not required to have a backgroundin healthcare helped PD patients, found that the prob-ability of technique survival times were similar betweenHC assisted PD and family assisted PD patients. Studiesthat focused on elderly concluded that the probability oftechnique failure was similar between HC (nurse)assisted PD patients and comparators including patientson self care PD [48] and traditional modalities (i.e., selfcare PD and in-center HD) [53]. The probability of tech-nique failure following an episode of peritonitis was alsosimilar between home-assistant assisted PD and self carePD and family assisted PD patients [49].Peritonitis rate was another outcome examined in PDstudies with comparators. In almost all of these studies,HC assisted PD patients and the comparators (includingfamily assisted PD among general PD populations [57],self care PD among elderly [48] and self care PD andfamily assisted PD among elderly [49]) had similar prob-abilities of being peritonitis free. In one study [52], HCassisted PD patients had lower peritonitis rates whencompared to self care PD. In another study [56], HCassisted PD patients had higher peritonitis rates whencompared to family assisted PD patients. However, thedifference in peritonitis rates observed in the latter studydisappeared when the effects of regular nurse visits fromdialysis centers to the HC assisted PD patients weretaken into consideration.Most of the PD studies with comparators that examinedpatient survival found a higher probability of mortalityamong HC assisted PD patients. This result continued tohold across different comparators including self care PDamong general PD populations [51,52], self care PD andfamily assisted PD among general PD populations [51],family assisted PD among general PD populations [57],and self care PD among elderly PD populations [48]. Twostudies about elderly populations were exceptions. In thefirst study, the risk of mortality did not differ between pa-tients receiving nurse assisted PD and those on traditionalmodalities [53]. In the second study, peritonitis-relatedmortality was similar among home-assistant assisted PDand self care PD and family assisted PD patients [49].The PD studies without comparators focused on vary-ing outcomes such as identifying critical elements of ahome visit [61] and exploring costs of RRTs [58]. Thestudies that considered PD patients with severe disabilityreported peritonitis rates that ranged from 1 episode per13.0 patient-months [60] to 20.1 patient-months [58]and hospitalization rates that ranged from 1 admissionper 6.0 patient-months [60] to15.3 patient-months [58].A recent study from Brazil [59] found 1 peritonitis epi-sode per 37.0 patient-months and 60% patient survivalat one year among a general PD population.HemodialysisThe HD study with a comparator [62] concluded thatpatients in HC group had improved on 15 of the 19 out-comes considered (including decreases in nausea, vomit-ing, headache, bone pain, weakness and fatigue anditching and improvements in general condition and thelevels of creatinine, potassium and phosphorus of theblood). The HD study without a comparator [63] fo-cused on patients diagnosed with terminal illness andfound that, on average, patients were hospitalized for9.43 days.Pre-dialysis and dialysisBased on survey results, more than three-fourths of PDand HD patients were very satisfied with the pre-dialysisand dialysis phase of their care after the implementationof HC program [64]. The HC team consisting of threenurses and one renal care assistant provided continuoussocial support to patients. The HC team also collectedinformation about patients’ life goals and provided infor-mation to them about their dialysis modalities.Risk of bias and confoundingWhile most studies had low risk of bias in many do-mains (Table 3), apart from two studies [51,52] that usedimputations techniques for missing information, loss tofollow-up was rarely discussed. Some of the studies[48,49,51-53,56,57] have taken into consideration con-founding variables such as age and Charlson ComorbidityIndex (CCI). The CCI summarizes the impact comorbidconditions have on survival by assigning higher weights tomore severe coexisting conditions such as metastatic car-cinoma and lower weights to less severe ones such as de-mentia [65-67]. While CCI is one of the most widely usedrisk adjustment techniques in observational studies, thecharacteristics of CKD populations may require multidi-mensional prognostic indices that take into account phys-ical, psychological, cognitive, functional and social factors[68]. One of the studies included in this SR reported onthe physical performance of patients using KarnofskyAydede et al. BMC Nephrology 2014, 15:118 Page 15 of 18http://www.biomedcentral.com/1471-2369/15/118Scale in addition to providing information on their comor-bidity scores [59]. Apart from the descriptive informationincorporated in the latter study, there were no studies thatincorporated multidimensional indices as another con-founding variable in their analysis.DiscussionOur SR revealed that most of the studies that examinedthe impact of HC services among CKD patients focusedon dialysis patients, in general, and PD patients, in par-ticular. Among RRTs, assisted PD provides an option forESRD patients who prefer home-based dialysis therapiesbut have barriers to self care including physical disabilityand cognitive impairment. HC assisted PD becomes es-pecially valuable for ESRD patients with additional bar-riers to self care such as social isolation. The currentincreases in the prevalence of elderly ESRD patientspartly explain the greater emphasis placed on assistedPD in the CKD HC literature.The HC assisted PD studies incorporated in this re-view mostly underscored clinically relevant outcomes forPD such as peritonitis rate and technique and patientsurvival. The findings show that technique survival andperitonitis rates for HC assisted PD patients were atleast similar to or better than those for self care PD andfamily assisted PD patients. The studies that found bet-ter technique survival [51,52] and peritonitis rates [52]for HC (nurse) assisted PD patients relied on nationallevel French registry using the same time period. Theavailability of HC assisted PD may reduce the likelihoodof adverse events by improving patient’s psycho-socialstatus and supporting them in adhering to the basicprinciples of PD including peritonitis prevention. Fur-ther studies are needed to examine if favorable outcomescontinue to hold for HC assisted PD patients in differentregions across the world.Most PD studies found a higher probability of mortalityamong HC assisted PD patients when compared to selfcare PD or family assisted PD. These studies indicated thatpatients in their HC assisted PD group were older andhad higher levels of comorbidities as captured by the CCI.The higher probability of mortality among HC assistedPD patients persisted in studies that controlled for ageand CCI differences across groups. The authors mostly at-tributed this finding to data insufficiencies in capturingdisabilities among PD populations. Apart from one study[59] that described comorbidity and physical performancein their study population, there were no studies that incor-porated multidimensional indices that take into accountphysical, psychological, cognitive, functional and socialfactors as another confounding variable in their analysis.The studies included in this SR provided limited infor-mation about the characteristics of the HC interven-tions. In general, technical requirements imposed on HCintervention based on the dialysis type used are wellknown among the CKD community. Additional studiesthat consider HC interventions with varying scope andfrequency and duration of visits in different CKD popu-lations will provide helpful information to the CKDcommunity, especially for those who are considering HCprograms for their own clinic/practice.One of the gaps in the literature that was identified byour SR is related to the provision of HC services amongnon-ESRD CKD populations. Apart from one study [64]that incorporated information about patient experienceswith the implementation of a HC program that affectedboth the dialysis and pre-dialysis phases of their care,there were no studies that explored the impact HC hason non-ESRD CKD populations. It is well known thatCKD is often accompanied by several comorbid condi-tions, is common among older people and its prevalenceincreases with age. As emphasized by the World KidneyDay 2014 Steering Committee [69], these characteristicsof CKD coupled with increased life expectancy world-wide call for further explorations into ways of optimizinghealth for elderly populations. The impact different HCservices might have in improving health among non-ESRD CKD patients is one such area that deserves fur-ther explorations.The lack of studies on the impact home palliative carehas on patients with CKD is another gap in the literaturethat was identified by our SR. The quality of life consid-erations for CKD patients who are at the advance stagesof their disease require focus on several issues includingthe management of their physical and psycho-socialsymptoms and the development of an advanced careplan that sets the goals for their care [70-74]. Studiesthat examine the impact home palliative care has on pa-tients with CKD who are at the advance stages of theirdisease will help further advance the integration of pal-liative and renal care.Our SR identified other gaps in the literature. Therewere no studies about HC provision among kidneytransplant patients. Studies related to HC provisionamong HD patients were limited to small samples.The HC interventions incorporated in the CKD litera-ture were mostly limited to nursing care for ESRD pa-tients. There were no studies about the provision ofhome support for activities of daily living or respite carefor caregivers of CKD patients. While HC may becomemore important as CKD severity increases and, in thecase of ESRD, it may be most useful for patients onhome-based dialysis modalities or for those who chooseconservative care, further studies are needed to quantifythese differing levels of HC use and its impact.One of the strengths of our study is the comprehen-sive SR conducted on a topic where there were, to thebest of our knowledge, no previous SR undertaken. Theself. HC, as encompassing a diverse set of medical anditations by conducting comprehensive database searches,Aydede et al. BMC Nephrology 2014, 15:118 Page 16 of 18http://www.biomedcentral.com/1471-2369/15/118extensive hand searches and expert consultations. Anotherlimitation is our inability to conduct a meta-analysis forour study. The diversity of patient populations, HC inter-ventions and outcomes studied made it impossible to con-duct a meta-analysis.ConclusionsIn this era of aging world population and medical andtechnical advances, chronic diseases, such as CKD, aregrowing in incidence and prevalence. HC may be usefulin providing a more efficient and higher quality care forCKD patients. However, a synthesis of evidence on theeffects of HC among CKD patients has not been under-taken. Our SR, which aimed at filling this void, revealedthat extant studies almost exclusively focused on nurseassisted HC patients examining mostly PD related clin-ical outcomes. Our study concluded that there are sev-eral gaps in the literature. Specifically, there were nostudies in areas such as home support for activities ofdaily living, palliative care at home or respite care forcaregivers of CKD patients, in general, or for ESRD pa-tients, in particular.AppendixMEDLINE Search Strategy:1. exp kidney diseases/2. exp renal replacement therapy/psycho-social services, is one of the health services re-search areas that are constantly evolving with limitedstandardization in terminology. Our study which focusedon the intersection of home care with CKD faced add-itional challenges given the changes in CKD definitionitself in the past years that is continuing through today[75]. We made an attempt to balance this fundamentallimitation by conducting comprehensive database searches,extensive hand searches and expert consultations. Secondlimitation of our study is the layered approached followedin study selection. Third limitation is the focus on stud-ies published in English. Given the diversity of HC ser-vices, resource and time considerations were crucialfactors in our decision to follow a layered study selectionapproach and to focus on studies published in English. Asindicated above, we made an attempt to balance these lim-comprehensive electronic database searches coupledwith hand searches and expert consultations resulted inthe identification of several gaps in the literature.Our study has several limitations. One of the limita-tions of our study is arising from the subject matter it-3. ((kidney or renal) adj2 (disease* or failure ordamage or insufficiency)).mp.4. ((kidney or renal) adj2 (transplant*5 or dysfunctionor therap*)).mp.5. (dialysis or dialyses or haemodialysis).mp.6. Kidney, Artificial/7. (kidney* adj artificial).mp.8. or/1-7 (540012)9. exp home care services/10. (domiciliary adj3 (care or service$ or nurs$)).mp.11. “home nurs$3”.mp.12. ((home or care) adj3 (nonprofession$ or non-professional$)).mp.13. (homemaker adj3 service$).mp.14. (home adj3 service$).mp.15. “home care”.mp.16. (home adj3 (renal or dialys$3 or hemodialy$3 orperitoneal)).mp.17. ((parenteral or nutrition or feeding) adj home).mp.18. (“hospital at home” or “hospital in the home” or“in-home care”).mp.19. “home health care”.mp.20. (Home adj3 (rehabilitation or occupational orphysical or physiotherap$ or social worker$ orspeech)).mp.21. Day Care/22. (palliative adj5 home).mp.23. ((caregiver$ or care-giver$ or carer$) adj3 “respitecare”).mp.24. ((long-term or long term) adj3 (home care orhome-care)).mp.25. activities of daily living.sh. and home.tw.26. (personal care adj3 home).mp.27. (self-care adj3 home).mp.28. (day adj3 care).mp.29. self care.sh. and home.tw.30. or/9-2931. 8 and 3032. limit 31 to (english language and yr=“1990-Current”)33. limit 32 to “all child (0 to 18 years)”34. 32 not 33.AbbreviationsCKD: Chronic kidney disease; RRT: Renal replacement therapy; ESRD: End-stagerenal disease; HC: Home care; PD: Peritoneal dialysis; HD: Hemodialysis;HHD: Home hemodialysis; SR: Systematic review; KDIGO: Kidney Disease:Improving Global Outcomes; RDPLF: French Language Peritoneal DialysisRegistry; CCI: Charlson Comorbidity Index; CCPD: Continuous cycling PD;CAPD: Continuous ambulatory PD.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsSKA contributed to the conception and design, analysis and interpretation ofresults, and drafted the manuscript. PK contributed to the conception anddesign, interpretation of results and provided input for manuscript revision.OD contributed to the interpretation of results and provided input formanuscript revision. AL contributed to the conception and design,7. Kurella M, Covinsky KE, Collins AJ, Chertow GM: Octogenarians andthe Mainstream. Ottawa, Ontario: CHCA; 2009.Aydede et al. BMC Nephrology 2014, 15:118 Page 17 of 18http://www.biomedcentral.com/1471-2369/15/11816. Prakash S, Perzynski AT, Austin PC, Wu CF, Lawless ME, Paterson JM, QuinnRR, Sehgal AR, Oliver MJ: Neighborhood socioeconomic status andbarriers to peritoneal dialysis: a mixed methods study. Clin J Am Socnonagenarians starting dialysis in the United States. Ann Intern Med 2007,146(3):177–183.8. Cook WL, Jassal SV: Functional dependencies among the elderly onhemodialysis. Kidney Int 2008, 73(11):1289–1295.9. Weiner DE, Scott TM, Giang LM, Agganis BT, Sorensen EP, Tighiouart H,Sarnak MJ: Cardiovascular disease and cognitive function in maintenancehemodialysis patients. Am J Kidney Dis 2011, 58(5):773–781.10. Brown EA: How to address barriers to peritoneal dialysis in the elderly.Perit Dial Int 2011, 31(Suppl 2):S83–S85.11. Jager KJ, Korevaar JC, Dekker FW, Krediet RT, Boeschoten EW: The effect ofcontraindications and patient preference on dialysis modality selectionin ESRD patients in the Netherlands. Am J Kidney Dis 2004, 43(5):891–899.12. Soni RK, Weisbord SD, Unruh ML: Health-related quality of life outcomesin chronic kidney disease. Curr Opin Nephrol Hypertens 2010, 19(2):153–159.13. Finkelstein FO, Arsenault KL, Taveras A, Awuah K, Finkelstein SH: Assessingand improving the health-related quality of life of patients with ESRD.Nat Rev Nephrol 2012, 8(12):718–724.14. Pagels AA, Soderkvist BK, Medin C, Hylander B, Heiwe S: Health-relatedquality of life in different stages of chronic kidney disease and atinitiation of dialysis treatment. Health Qual Life Outcomes 2012, 10:71.15. Canadian Healthcare Association: Home Care in Canada: From the Margins tointerpretation of results and provided input for manuscript revision. Allauthors have read and approved the final manuscript.AcknowledgementsThis research is supported by an Allied Health Research grant (no.KFOC110022)from the Kidney Foundation of Canada. The authors thank Sharon Stevens forelectronic searches. Research assistants Simon Tai, Mithila Makhijani, ThomasFerguson and Michelle Wong provided excellent support in the earlier phasesof this study.Author details1School of Population and Public Health, The University of British Columbiaand Provincial Health Services Authority, 700-1380 Burrard Street, Vancouver,BC V6Z 2H3, Canada. 2Faculty of Medicine, Section of Nephrology, Universityof Manitoba and Seven Oaks General Hospital, Room 2PD02 – 2300McPhillips Street, Winnipeg, MB R2V 3M3, Canada. 3British ColumbiaProvincial Renal Agency, Providence Bldg, Room 570.4, 1081 Burrard Street,Vancouver, BC V6Z 1Y6, Canada. 4Division of Nephrology, Providence Bldg,Room 6010A, The University of British Columbia and British ColumbiaProvincial Renal Agency, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.Received: 5 February 2014 Accepted: 19 June 2014Published: 18 July 2014References1. 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