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Background More than 6200 End Stage Renal Disease patients in the Netherlands are dependent on dialysis, either performed at home or in a dialysis centre. Visiting a dialysis centre three times a week is considered a large burden by many patients. However, recent data regarding the effects of dialysis at home on quality of life, clinical outcomes, and costs compared with in-centre haemodialysis are lacking. Methods The Dutch nOcturnal and hoME dialysis Study To Improve Clinical Outcomes (DOMESTICO) is a nationwide, prospective, observational cohort study that will include adult patients starting with a form of dialysis. Health-related quality of life, as the primary outcome, clinical outcomes and costs, as secondary outcomes, will be measured every 3–6 months in patients on home dialysis, and compared with a control group consisting of in-centre haemodialysis patients. During a 3-year period 800 home dialysis patients (600 peritoneal dialysis and 200 home haemodialysis patients) and a comparison group of 800 in-centre haemodialysis patients will be included from 53 Dutch dialysis centres (covering 96% of Dutch centres) and 1 Belgian dialysis centre (covering 4% of Flemish centres). Discussion DOMESTICO will prospectively investigate the effect of home dialysis therapies on health-related quality of life, clinical outcomes and costs, in comparison with in-centre haemodialysis. The findings of this study are expected to ameliorate the shared decision-making process and give more guidance to healthcare professionals, in particular to assess which type of patients may benefit most from home dialysis. Trial registration The DOMESTICO study is registered with the National Trial Register on (number: NL6519, date of registration: 22 August 2017) and the Central Committee on Research Involving Human Subjects (CCMO) (number: NL63277.029.17).

For haemodialysis patients there is always a risk of a blockage of the access to the bloodstream. Periodical measuring of the blood flow can timely signal an imminent blockage, upon which a dotter procedure can prevent complete blockage. This strategy is already successfully applied at the MUMC+, although the available scientific literature does not confirm this success yet. The described strategy could possibly be improved by increasing the measuring frequency by means of using innovative, in the dialysis equipment integrated techniques. Two techniques were studied: one of these turned out comparable to the present golden standard measuring method with regard to reliability.

Around 40% of patients undergoing chronic hemodialysis are suffering from complicated protein-energy wasting (PEW) syndrome. However, routinely assess PEW is not easily achievable in busy clinical settings. The current research focuses on researching the clinical and biomedical factors that are associated with PEW and their associations with adverse outcomes in dialysis patients. The current research introduced a nutritional composite score, which can be used and applied in practice to monitor patients’ nutritional status. Lots of times, it is tried to encourage malnourished patients to eat more, however, patients are also recommended to avoid overeating (e.g. higher levels of serum phosphate found to be associated with worst outcomes). Later, the simplified creatinine index is introduced, which can be used to monitor muscle mass in resource-limited settings. Last, the findings of lower levels of low-density lipoproteins and its association with a higher risk of mortality, add insights to the fact that malnourished patients are with a higher risk of death. All the work conducted by the current research provides additional clinically relevant insights into the links between factors that are associated with PEW and outcomes in the dialysis population.

This thesis, “Clinical factors impacting quality of life and outcomes through the transition from pre-dialysis CKD to early dialysis treatment”, examines clinical factors that improve dialysis start and patient survival. The gathered data suggests that patient differences, which affect the way patients start dialysis, may be present in late stage CKD. Clinical interventions related to blood pressure, dialysis preparation, and home therapy use may benefit patients. The way patients start dialysis and dialysis changes in the first treatment year may impact quality of life perceptions. CKD clinical data analysis may help to personalize CKD care and improve the transition to dialysis start.

This thesis focuses on body composition, physical activity and quality of life in pre-dialysis and dialysis patients. The transitional phase of pre-dialysis to dialysis and the first six months after starting dialysis were also studied. Although this is one of the most critical phases in the lives of chronic renal disease patients, only few studies have been conducted into this subject. The findings of this thesis clearly show the importance of gaining more insight into changes and risks that occur after starting dialysis treatment in order to reduce the risk of common complications.

Most patients with terminal kidney failure undergo hemodialysis three times a week in a hospital. Hemodialysis can also be done at home, which allows for longer (night) and more frequent (intensive) dialysis. In addition to the known benefits of intensive home hemodialysis on life expectancy, quality of life, and cardiovascular functioning, this dissertation demonstrates additional advantages. These include increased stability of blood pressure and heart function, improved waste removal during dialysis, and protective effects in pregnant women and older dialysis patients. Finally, this dissertation also reveals that intensive home hemodialysis can reduce costs compared to traditional hemodialysis offered by hospitals.