Post-dialysis "pre-dialysis" care: the cart before the horse--advanced practice nurse intervention and impact on modality selection.

Most institutions with dialysis programs have developed pre-dialysis clinics, which provide education and medical management leading up to the need for dialysis or transplantation. Another large group of individuals start dialysis acutely, for a variety of reasons, and are often started emergently in hospital with little or no preparation or education for dialysis. Historically, a vast majority of this group of patients in our institution remained on incentre hemodialysis. The Division of Nephrology at the University Health Network (UHN), a large teaching hospital in Toronto, Ontario, developed a program by which a consulting advanced practice nurse (cAPN) intervened with these individuals starting dialysis emergently, with the goal of encouraging home dialysis. In the first 26 months of this role, the percentage of patients who started dialysis acutely and who stayed on incentre hemodialysis (HD) decreased from 87% to 33%, and the percentage who chose home dialysis increased from 13% to 67%.