Correlates and outcomes of fatigue among incident dialysis patients

Fatigue is associated with high prevalence and severity of physical and emotional symptoms in patients on chronic hemodialysis

PURPOSE

The symptom burden of fatigued hemodialysis patients is poorly known. We aimed to investigate possible differences in the prevalence and severity of symptoms between fatigued and not fatigued patients on chronic hemodialysis.

METHODS

All prevalent patients on chronic hemodialysis referring to the Hemodialysis Service between January 2016 and June 2017 were considered eligible. The Dialysis Symptom Index (DSI) questionnaire was performed during the dialysis treatment. Patients underwent assessment of fatigue using the Italian version of the vitality scale of the SF-36 (SF-36VS).

RESULTS

We studied 137 patients: 107 (78.1%) were fatigued and 30 (31.9%) were non-fatigued. The median [95% CI] number of symptoms was 15 [14-16] for patients who reported fatigue and 9 [8-19] for the non-fatigued (P < 0.0001). In fatigued patients, with respect to non-fatigued ones, the prevalence of dry skin, itching, muscle soreness, bone or joint pain, restless legs, shortness of breath, feeling sad, feeling anxious, difficulty concentrating, and difficulty becoming sex aroused was significantly higher. Restless legs, feeling sad, difficulty concentrating, and difficulty becoming sex aroused were symptoms independently associated with fatigue. The severity of dry skin, trouble staying asleep, and bone/joint pain was higher in fatigued patients.

CONCLUSION

Fatigued hemodialysis patients report suffering from physical and emotional symptoms more frequently than non-fatigued patients. This finding suggests the need to accurately and routinely define the symptom burden of chronic hemodialysis patients and may help to investigate eventually common underlying pathogenic mechanisms of symptoms in these patients.

Relationship between fatigue symptoms and subjective and objective indicators in hemodialysis patients

PURPOSE

The purpose of the study was to investigate the major factors affecting fatigue symptoms and to examine the relationships between fatigue symptoms and subjective and objective indicators in patients on hemodialysis (HD).

METHODS

Patients on HD who met the inclusion criteria were chosen from two grade A tertiary general hospitals by convenience sampling and cross-sectional survey methods.

RESULTS

A total of 511 patients were included in the study. The morbidity rate of fatigue in patients on HD was 61.6%, and the median fatigue level was 3.91. Fatigue and subjective indicators showed a mild-moderate relationship (0.3 < all |r| < 0.6, all P < 0.001), whereas a weak correlation was found between fatigue and objective indicators (all |r| < 0.2, all P < 0.05). Multivariate analysis showed that subjective indicators, including employment, exercise time, appetite, the vitality of 36-item Short Form Health Survey, perceived social support, intrafamilial support, cramping, headache, chest tightness, and whole-body pain, as well objective indicator, such as serum intact parathyroid hormone levels, were the influence factors of fatigue in patients on HD.

CONCLUSION

The prevalence of fatigue symptoms was high and the level of fatigue was moderate in patients on HD. Subjective and objective indicators can both affect fatigue symptoms in patients on HD.

'It's when you're not doing too much you feel tired': A qualitative exploration of fatigue in end-stage kidney disease

BACKGROUND

Fatigue is commonly experienced in end-stage kidney disease (ESKD) patients. In order to develop patient-centred psychosocial interventions to help patients manage fatigue symptoms, a more in-depth understanding regarding the experience of fatigue is needed.

OBJECTIVE

The objective of this study was to explore renal patients' experiences of fatigue, across renal replacement therapy (RRT) modalities.

METHODS

Twenty-five in-depth semi-structured interviews were conducted. Interviews were audio-taped, transcribed, and analysed using inductive thematic analysis.

RESULTS

Main themes included the strong role of the illness and treatment in the aetiology of fatigue. Two contrasting streams of illness-fatigue interpretations emerged: catastrophizing versus normalizing. Participants emphasized the importance of having a sense of purpose in facilitating active management of fatigue. Many participants described the consequences of fatigue on their functioning. Low mood, frustration, and anger were common emotional consequences of fatigue. Three dominant fatigue management strategies emerged: one related to accommodation of activities around fatigue, another on increasing activities to counteract fatigue, and the third one revolved around self-compassion. Social support emerged as an important aspect of the fatigue experience, serving as a source of motivation, yet participants were wary of becoming a burden to others.

CONCLUSION

Findings identify casual attributions, behavioural and emotional reactions, management strategies, and facilitators of active management of fatigue in ESKD. Untying fatigue from the illness and treatment may help patients to develop alternative less catastrophic perceptions of fatigue, increase their perception of control over fatigue, and facilitate active fatigue management. Statement of contribution What is already known on this subject? Fatigue is persistent and debilitating in end-stage kidney disease (ESKD), with no consistent treatment model. Promising evidence is available for psychological fatigue interventions in other chronic conditions. There is a gap in studies looking at the fatigue experiences of patients with ESKD across renal replacement therapies. What does this study add? Fatigue is not inherently negative, but shaped by patients' beliefs and behaviours. Findings provide novel insights, for example, on the important role social support seems to play in fatigue. An in-depth understanding of fatigue may help to inform a future patient-centred intervention in ESKD.

Cognitive-behavioural therapy (CBT) for renal fatigue (BReF): a feasibility randomised-controlled trial of CBT for the management of fatigue in haemodialysis (HD) patients

INTRODUCTION

Fatigue is one of the most common and disabling symptoms in end-stage kidney disease, particularly among in-centre haemodialysis patients. This two-arm parallel group feasibility randomised controlled trial will determine whether a fully powered efficacy trial is achievable by examining the feasibility of recruitment, acceptability and potential benefits of a cognitive-behavioural therapy (CBT)-based intervention for fatigue among in-centre haemodialysis patients.

METHODS

We aim to recruit 40 adult patients undergoing in-centre haemodialysis at secondary care outpatient dialysis units, who meet clinical levels of fatigue. Patients will be randomised individually (using a 1:1 ratio) to either a 4-6 weeks' CBT-based intervention (intervention arm) or to a waiting-list control (control arm). The primary feasibility outcomes include descriptive data on numbers within each recruiting centre meeting eligibility criteria, rates of recruitment, numbers retained postrandomisation and treatment adherence. To assess the potential benefits of the cognitive-behavioural therapy for renal fatigue intervention, secondary self-report outcomes include measures of fatigue severity (Chalder Fatigue Questionnaire), fatigue-related functional impairment (Work and Social Adjustment Scale), sleep quality (Pittsburgh Sleep Quality Index), depression (Patient Health Questionnaire-9) and anxiety (Generalised Anxiety Disorder-7). Changes in fatigue perceptions (Brief Illness Perception Questionnaire), cognitive and behavioural responses to fatigue (Cognitive and Behavioural Responses to Symptoms Questionnaire), sleep hygiene behaviours (Sleep Hygiene Index) and physical activity (International Physical Activity Questionnaire-short form) will also be explored. These self-report measures will be collected at baseline and 3 months postrandomisation. Nested qualitative interviews will be conducted postintervention to explore the acceptability of the intervention and identify any areas in need of improvement. The statistician and assessor will be blinded to treatment allocation.

ETHICS AND DISSEMINATION

A National Health Service (NHS) Research Ethics Committee approved the study. Any amendments to the protocol will be submitted to the NHS Committee and study sponsor.

TRIAL REGISTRATION NUMBER

ISRCTN91238019;Pre-results.

Methodological considerations in using patient reported measures in dialysis clinics

Patient reported measures (PRMs), including patient-reported outcomes, play a critical role in dialysis care. The usage of PRMs is extensive in dialysis clinics. While there are excellent PRMs to choose from, and their implementation as part of quality improvement and performance monitoring is extensive, there are still methodological challenges to be addressed. In this paper, we identify key methodological concerns around use of PRMs in dialysis centers in the United States and make recommendations for improving the use of PRMs in dialysis related to Selection of PRMs, Mode of Administration, and Support for PRM Use. These recommendations include: (1) Continue the use of Kidney Disease Quality of Life 36-item survey (KDQOL™-36) for dialysis centers' internal quality improvement activities and the In-Center Hemodialysis Consumer Assessment of Health Care Providers and Systems (ICH-CAHPS survey®) for public dialysis center performance monitoring, but promote efforts to modify these instruments by incorporating PROMIS general health items (KDQOL-36) and reducing the length of the ICH-CAHPS. (2) Adopt a PRM of whether dialysis patients have been informed about all dialysis and transplant options. (3) Evaluate equivalence between electronic and paper versions of PRMs prior to widespread use of electronic administration. (4) Explore reimbursement of costs of PRM administration by the Centers for Medicare and Medicaid Services and kidney organizations. (5) Continue development of provider trainings in PRM administration and interpretation. These recommendations will help dialysis care decision-makers, clinicians, and applied researchers take the next steps toward enhancing PRM use in dialysis.

1-year course of fatigue in patients on chronic hemodialysis

PURPOSE

Fatigue is common in end-stage renal disease patients receiving hemodialysis, reduces significantly their quality of life and is associated with all-cause and cardiac-related mortality. Unfortunately, little is known about the course of fatigue in patients on chronic hemodialysis.

METHODS

The Vitality Subscale of the SF-36 (SF-36 VS), Short-Form Health Survey, was administered to 45 patients in January (T1), June (T2) and November (T3) 2015.

RESULTS

The score of the SF-36 VS did not differ significantly among T1, T2 and T3. Similarly, the 1-year course of the SF-36 Vitality Subscale score did not differ significantly among T1, T2 and T3 after stratification of patients for sex, age, BMI, IADL and Charlson. Between T1 and T2, 21 out of 45 patients (46.6%) changed their fatigue status: 8 fatigued patients became not-fatigued and 13 not-fatigued patients became fatigued. Between T2 and T3, 12 out of 45 (26.6%) patients changed their fatigue status: 5 fatigued patients became not-fatigued and 7 not-fatigued patients became fatigued. Between T1 and T3, 19 out of 45 patients (42.2%) changed their fatigue status: 6 fatigued patients became not-fatigued and 13 not-fatigued became fatigued.

CONCLUSION

The present study is the first to identify variations in fatigue status among patients on chronic hemodialysis during 1-year course. These findings suggest to frequently assess the presence and severity of fatigue in patients on chronic hemodialysis.

The role of psychological factors in fatigue among end-stage kidney disease patients: a critical review

Fatigue is a common and debilitating symptom, affecting 42-89% of end-stage kidney disease patients, persisting even in pre-dialysis care and stable kidney transplantation, with huge repercussions on functioning, quality of life and patient outcomes. This paper presents a critical review of current evidence for the role of psychological factors in renal fatigue. To date, research has concentrated primarily on the contribution of depression, anxiety and subjective sleep quality to the experience of fatigue. These factors display consistent and strong associations with fatigue, above and beyond the role of demographic and clinical factors. Considerably less research is available on other psychological factors, such as social support, stress, self-efficacy, illness and fatigue-specific beliefs and behaviours, and among transplant recipients and patients in pre-dialysis care. Promising evidence is available on the contribution of illness beliefs and behaviours to the experience of fatigue and there is some indication that these factors may vary according to treatment modality, reflecting the differential burdens and coping necessities associated with each treatment modality. However, the use of generic fatigue scales casts doubt on what specifically is being measured among dialysis patients, illness-related fatigue or post-dialysis-specific fatigue. Therefore, it is important to corroborate the available evidence and further explore, qualitatively and quantitatively, the differences in fatigues and fatigue-specific beliefs and behaviours according to renal replacement therapy, to ensure that any model and subsequent intervention is relevant and grounded in the experiences of patients.

C reactive protein and depressive symptoms in hemodialysis patients: A questionable association

INTRODUCTION

Patients with advanced chronic kidney disease (CKD) on haemodialysis (HD) may have increased C reactive protein (CRP) values and depressive symptoms. There is debate about the strength and nature of previously reported associations. We investigated these issues in a cohort of patients on HD.

METHODS

We screened for depressive symptoms using two valadiated depression screening tools: the Beck Depression Inventory-II (BDI-II), Patient Health Questionnaire (PHQ-9). Demographic and clinical correlates of depression symptoms were eveluated in adjusted linear and logistic regression models, which included extra renal comorbidity and high CRP (>5 mg/L).

FINDINGS

Three hundred and ninety-six HD patients were studied; 63.1% male, mean age 63.1 ± 16.4 years, median CRP 6 (5-15) mg/L. Depression scores were similar in those with normal and high CRP (BDI-II (9(5-17) vs. 11(6-20)) or PHQ (4(2-9) vs. 6(2-10)). In adjusted multivariable regression BDI-II scores were associated with previous history of depression (β 10.8, P < 0.001), serum albumin (β 0.41, P < 0.001), anuria (β 2.4, P < 0.037), diabetes (β 2.7, P = 0.033), and age (β -0.10, P = 0.009). High CRP was not independently associated with BDI-II (β 2.20, P = 0.057), though was with PHQ-9 (β 1.20, P = 0.046). In logistic regression those with high CRP were 1.9 times more likely to score ≥16 on BDI-II screening (P = 0.016), but did not relate significantly to a PHQ-score ≥10.

DISCUSSION

A relationship was observed between CRP and depression symptoms, though the effect was small, of unlikely clinical significance, and inconsistent between depression measures. Previous reports of this association may reflect overlap between symptoms of depression and advanced CKD.

Apoprotein B/Apoprotein A-1 Ratio and Mortality among Prevalent Dialysis Patients

BACKGROUND AND OBJECTIVES

In dialysis patients, the associations between apoprotein profile and all-cause or cardiovascular disease (CVD)-related mortality are not well known. We, therefore, investigated whether apoprotein levels are associated with these events.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We undertook a prospective observational cohort study of prevalent hemodialysis patients aged ≥18 years (n=1081), who were followed for 4 years (2011-2014). Outcomes were all-cause and CVD-related mortality. Predictors used were baseline apoprotein levels, particularly the apoprotein B (apo B)/ apoprotein A-1 (apo A-1) ratio. A Cox regression analysis was used to calculate the hazard ratios (HRs) for mortality. Apo A-1, apo B, and apo B/ apo A-1 ratio were analyzed with adjustments in three models: model 1, basic adjustment for age and sex; model 2, basic adjustments plus dialysis conditions (dialysis vintage, mean predialysis systolic blood pressure, dry weight, and mean intradialytic weight gain); and model 3, model 2 plus metabolic and inflammatory conditions (basal kidney disease, serum albumin, C-reactive protein level, and statin use).

RESULTS

Of the 1081 patients included in the study, 203 deaths were recorded, 92 of which were related to CVD. The apo B/ apo A-1 ratio was significantly associated with all-cause and CVD-related mortality when analyzed by 1-SD increments or quartile IV versus I in all models. In model 3, HRs and 95% confidence intervals (95% CIs) for 1-SD increments of apo B/ apo A-1 ratio for all-cause mortality or CVD-related mortality were: HR, 1.16 (95% CI, 1.00 to 1.35), or HR, 1.38 (95% CI, 1.11 to 1.71), respectively, and for quartile IV versus I: HR, 1.65 (95% CI, 1.05 to 2.57), or HR, 2.56 (95% CI, 1.21 to 5.40), respectively. Apo A-1 was significantly associated with both mortalities in models 1 and 2. However, apo B was only significantly associated with CVD-related mortality in model 3.

CONCLUSIONS

Apoprotein measurement, especially the apo B/ apo A-1 ratio, was significantly associated with all-cause and CVD-related mortality in prevalent dialysis patients.

Functional assessment of chronic illness therapy-the fatigue scale exhibits stronger associations with clinical parameters in chronic dialysis patients compared to other fatigue-assessing instruments

Background. Patients with end-stage renal disease (ESRD) have a high symptom burden, among which fatigue is highly prevalent. Many fatigue-assessing instruments exist, but comparisons among instruments in this patient population have yet to be investigated. Methods. ESRD patients under chronic hemodialysis were prospectively enrolled and seven types of fatigue instruments were administered: Brief Fatigue Inventory (BFI), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), Fatigue Severity Scale (FSS), Lee Fatigue Scale (LFS), Fatigue Questionnaire (FQ), Fatigue Symptom Inventory (FSI), and Short-Form 36-Vitality (SF36-V). Using these instruments, we investigated the correlation between fatigue severity and clinical/biochemical parameters, including demographic/comorbidity profile, dialysis-related complications, and frailty severity. We used regression analysis with serum albumin and frailty severity as the dependent variables to investigate the independent correlations. Results. A total of 46 ESRD patients were enrolled (average age of 67 ± 11.6 years), and 50% of them had type 2 diabetes mellitus. Results from the seven tested instruments showed high correlation with each other. We found that the fatigue severity by FACIT-F was significantly associated with age (p = 0.03), serum albumin (p = 0.003) and creatinine (p = 0.02) levels, while SF36-V scores were also significantly associated with age (p = 0.02) and serum creatinine levels (p = 0.04). However, the fatigue severity measured by the FSS, FSI, FQ, BFI, and LFS did not exhibit these associations. Moreover, regression analysis showed that only FACIT-F scores were independently associated with serum albumin levels and frailty severity in ESRD patients. Conclusion. Among the seven fatigue-assessing instruments, only the FACIT-F yielded results that demonstrated significant and independent associations with important outcome-related features in ESRD patients.

Pursuing minimally disruptive medicine: disruption from illness and health care-related demands is correlated with patient capacity

BACKGROUND

Chronic conditions burden patients with illness and treatments. We know little about the disruption of life by the work of dialysis in relation to the resources patients can mobilize, that is, their capacity, to deal with such demands. We sought to determine the disruption of life by dialysis and its relation to patient capacity to cope.

METHODS

We administered a survey to 137 patients on dialysis at an academic medical center. We captured disruption from illness and treatment, and physical, mental, personal, social, financial, and environmental aspects of patient capacity using validated scales. Covariates included number of prescriptions, hours spent on health care, existence of dependents, age, sex, and income level.

RESULTS

On average, patients reported levels of capacity and disruption comparable to published levels. In multivariate regression models, limited physical, financial, and mental capacity were significantly associated with greater disruption. Patients in the top quartile of disruption had lower-than-expected physical, financial, and mental capacity.

CONCLUSIONS

Our sample generally had capacity comparable to other populations and may be able to meet the demands imposed by treatment. Those with reduced physical, financial, and mental capacity reported higher disruption and represent a vulnerable group that may benefit from innovations in minimally disruptive medicine.

Treating hypertension in hemodialysis improves symptoms seemingly unrelated to volume excess

BACKGROUND

Among hemodialysis patients, probing dry weight is an effective strategy for improving control of hypertension. Whether controlling hypertension improves or worsens symptoms among such patients remains unclear. The purpose of the study was to develop a tool to evaluate symptoms and examine the relationship of the change in these symptoms with blood pressure (BP) control.

METHODS

Among patients participating in the Hemodialysis Patients Treated with Atenolol or Lisinopril (HDPAL) randomized controlled trial, a confirmatory factor analysis (CFA) was performed to establish the relationship between symptoms and organ systems. Next, the change in symptom scores pertaining to organ systems was analyzed using a mixed model. Finally, the independent effect of lowering home BP on change in symptoms was evaluated.

RESULTS

Among 133 participants where symptoms were available at baseline, CFA revealed four level 1 domains: gastrointestinal symptoms, dialysis-related symptoms, cardiovascular symptoms and general symptoms. All except dialysis-related symptoms were ascribed to uremia (level 2 domain). Uremic symptoms improved over 6 months and then increased. Dialysis-related symptoms (fatigue, cramps and orthostatic dizziness) did not worsen despite lowering home BP. Probing dry weight was independently associated with an improvement in cardiovascular symptoms such as shortness of breath.

CONCLUSIONS

Reducing BP through the use of a strategy that includes volume control and medication improves symptoms seemingly unrelated to volume excess. In long-term hemodialysis patients, treating hypertension using home BP measurements may improve well-being.

A 4-month programme of in-centre nocturnal haemodialysis was associated with improvements in patient outcomes

BACKGROUND

Extended periods of haemodialysis (HD) can improve patient outcomes. In-centre nocturnal haemodialysis (INHD) should be explored as a method of offering extended periods of HD to patients unsuitable for or unable to perform home therapy.

METHODS

Ten self-selecting, prevalent HD patients started an INHD programme to assess feasibility and patient satisfaction. Quality-of-life (QOL) measures were evaluated at enrolment and after 4 months of INHD using the EQ-5D, the Hospital Anxiety and Depression Scale (HADS) and the SF-12 questionnaires. Demographic, biochemical and haematological data and data on dialysis adequacy were collected before starting INHD and after 4 months.

RESULTS

Three of the 10 patients failed to complete the 2-week run-in period. Seven patients completed the 4-month programme, with mean dialysis time of 355 ± 43.92 min throughout the period. The EQ-5D visual analogue score improved from 48 ± 16.89 to 72 ± 13.2 (P = 0.003) and the HADS anxiety score decreased from 9 ± 5.83 to 3.57 ± 3.04 (P = 0.029). The urea reduction ratio improved from 71.57 ± 2.29% to 80.43 ± 3.101% (P < 0.001), with improvements in phosphate control, reducing to within the target range from 1.73 ± 0.6 to 1.2 ± 0.2 (P = 0.08). Ultrafiltration (UF) volumes increased during the study from 2000 ± 510 to 2606 ± 343 mL (P = 0.015); there was a significant reduction in mean UF rate adjusted for body weight from 6.47 ± 1.71 to 4.61 ± 1.59 mL/kg/h (P = 0.032). Sensitivity analyses confirmed the significance of these results.

CONCLUSIONS

This single-centre study showed a 4-month programme of extended hours INHD is safe and associated with improvements in QOL measures, decreased UF rates and measures of dialysis adequacy. These data have been used to expand our service and inform the design of future randomized controlled trials to examine medical endpoints.

Levels of hepatocyte growth factor in serum correlate with quality of life in hemodialysis patients

PURPOSE

Patients with end stage renal failure (ESRD) report low quality of life and inflammation may be one of the contributing factors. We studied if the hemodialysis induced inflammation correlates with the patients quality of life.

METHODS

Study was performed in 76 (35 males and 41 females) ESRD patients treated with hemodialysis. Effect of one dialysis session on blood concentration of Vascular Endothelial Growth Factor (VEGF), Hepatocyte Growth Factor (HGF), Interleukin 6 (IL6) and Monocyte Chemoattractant Protein-1 (MCP-1) was studied. Results were correlated with answers given by patients to a short questionnaire composed of questions from Kidney Disease Quality of Life Short Form (KDQoL-SF) questionnaire.

RESULTS

Hemodialysis induced increase of serum level of HGF (+117%) and IL-6 (+17%). Declared by patients health status correlated with their age, GFR, kt/V and hemodialysis induced change in serum IL6 and HGF level (R(2) = 0469, P < 0.001). Physical activity correlated with age, serum IL-6 and hemodialysis induced change in serum HGF and VEGF (R(2) = 0.362, P < 0.001). Presence of social/mental problems during previous 4 weeks correlated with age, serum HGF and hemodialysis induced changes in serum HGF and VEGF levels (R(2) = 0.333, P < 0.001). Interference of the kidney disease with daily life activities correlated with age, serum VEGF and hemodialysis induced change in serum HGF and IL6 levels (R(2) = 0.422, P < 0.001).

CONCLUSION

Inflammation correlates with reduced quality of life in ESRD. Low hemodialysis-induced release of the anti-inflammatory cytokine HGF correlates with impaired quality of life in that group of patients.

Achievement of guideline targets in elderly patients on hemodialysis: a multicenter study

OBJECTIVES

Advanced age is associated with shorter survival on dialysis. The aim of the present study was to compare the adherence with KDOQI guideline targets and the association between mortality and satisfying the guidelines targets between hemodialysis patients aged 65 years and over and those younger than 65 years.

METHODS

Data were collected using a questionnaire sent to all 46 HD centers in Serbia with totally 3868 HD patients. The 24 centers responded and sent the data on all patients aged 18 years or older that were on regular HD for more than 3 months (2153 patients, 1320 males, aged 18-90 years). Data are presented in two groups: a group of patients younger than 65 years (1438, 66.8 %) and a group of patients aged 65 years and over (715, 33.2 %). The percentage of patients whose values failed to meet the targets recommended by KDOQI Clinical Practice Guidelines was calculated for dialysis dose (spKt/V), hemoglobin, serum phosphorus, serum calcium and plasma iPTH (150-300 pg/mL). Patients were followed from enrollment until their death, kidney transplantation, departure from the center or the end of the study.

RESULTS

Elderly patients were more likely to have hypertension, significantly lower systolic and diastolic blood pressure and smaller dialysis vintage than younger patients. They were less frequently treated with high-flux membranes and hemodiafiltration and they had significantly lower number of dialysis hours per week and significantly lower interdialytic weight gain. They used ESA and phosphate binders less frequently than younger patients (p < 0.001 and p = 0.002). Older patients had similar Kt/V as younger ones but they had significantly more frequent Hb level outside the target range than younger patients. During the year follow-up period, by using a Cox proportional hazards model it has been confirmed that age, dialysis vintage, weekly dialysis time and target values for Kt/V were significant independent predictors of time to death for younger patients and gender, dialysis vintage and iPTH were independent predictor of time to death for older patients.

CONCLUSION

Despite less favorable dialysis prescription, older patients had similar Kt/V and less frequent deviations from the target values proposed by KDOQI for serum phosphorus and iPTH but more frequent deviation for Hb value as compared with younger patients. Risk factors for mortality differ between older and younger patients; out of five KDOQI targets, only Kt/V proved to be a significant risk factor for mortality for younger and iPTH for older patients.

The effectiveness and safety of modest exercise in Japanese patients with chronic kidney disease: a single-armed interventional study

BACKGROUND

Poor physical ability and skeletal muscle wasting are common in chronic kidney disease (CKD) patients, who may experience a decline in daily activity and, in turn, increased mortality. The purpose of this study was to evaluate the effectiveness and safety of modest exercise in patients with stable CKD.

METHODS

Forty-seven CKD patients were enrolled in a 6-month group program for aerobic and resistance exercise by self-training. Parameters of physical function and clinical laboratory markers, including renal function, were measured.

RESULTS

The International Physical Activity Questionnaire score improved from a baseline of 36.6 ± 13.8 to 40.1 ± 14.8 after the exercise program (P < 0.001). The number of daily steps increased from 6141 ± 2620 to 7679 ± 3026 (P < 0.001). We detected significant changes in the 30-s chair stand test (from 20.7 ± 5.3 to 26.0 ± 5.9 repetitions; P < 0.001), single-foot standing test (from 53.0 ± 44.3 to 68.4 ± 43.0 s; P = 0.001) and 6-min walk (from 501.6 ± 63.8 to 528.7 ± 71.8 m; P = 0.02). Moreover, body weight, waist circumference, and blood pressure were significantly reduced. No significant deterioration was observed in the estimated glomerular filtration rate. Proteinuria significantly decreased in 21 patients.

CONCLUSION

Our modest exercise program improved the physical performance of CKD patients without deterioration of renal function. These results suggest that exercise rather than excess rest should be recommended for CKD patients to avoid muscle wasting.

An intradialytic increase in serum interleukin-6 levels is associated with an increased mortality in hemodialysis patients

BACKGROUND

The inflammatory marker interleukin-6 (IL-6) increases early in the inflammatory cascade. The aim of this study was to evaluate whether an increase in serum IL-6 levels during a hemodialysis (HD) session is associated with mortality.

METHODS

57 adult patients treated with HD for more than 1 month were prospectively studied over a 3-year follow-up period. Demographic and clinical data were collected and blood samples were drawn before and after a midweek HD session. Events of death and censoring were recorded.

RESULTS

During the 3-year follow-up, 50.8% of the patients died. In univariate Cox regression analysis, an increase in IL-6 levels during HD was associated with an increased mortality (HR 1.41 per pg/ml; 95% CI 1.06 to 1.88; P = .017). In multivariate Cox models, the only independent predictors of all-cause mortality were: an increase in IL-6 levels during dialysis (HR 1.46 per pg/ml; 95% CI 1.08 to 1.98; P = .014), higher baseline C-reactive protein (CRP) levels and older age. When predictors of an increase in serum IL-6 levels during HD were introduced into the model, mortality was still significantly associated with IL-6 elevation during dialysis (HR 1.47 per pg/ml, 95% CI 1.01 to 2.14; P = .045).

CONCLUSIONS

A rise in serum IL-6 levels during a single HD session is associated with a higher mortality among HD patients, independent of predialysis CRP or IL-6 levels. The results may imply the presence of an intradialytic inflammatory response that affects survival in HD patients.

The impact of depression on fatigue in patients with haemodialysis: a correlational study

AIMS AND OBJECTIVES

To investigate the fatigue levels and important fatigue predictors for patients undergoing haemodialysis.

BACKGROUND

Fatigue is a common symptom for haemodialysis patients. With its debilitating and distressing effects, it impacts patients in terms of their quality of life while also increasing their mortality rate.

DESIGN

A descriptive correlational study.

METHODS

Convenience sampling was conducted at six chosen haemodialysis centres in Southern Taiwan. Data were collected via a structured questionnaire from 193 haemodialysis patients. The scales involved in this study were socio-demographic details, the Center for Epidemiologic Studies Depression Scale, and the Fatigue Scale for haemodialysis patients. Data analysis included percentages, means, standard deviations and hierarchical multiple regression analysis.

RESULTS

The fatigue level for haemodialysis patients was in the moderate range. Results from the hierarchical multiple regression analysis indicated that age, employment status, types of medications, physical activity and depression were significant. Of those variables, depression had the greatest impact on the patients' fatigue level, accounting for up to 30·6% of the explanatory power. The total explanatory power of the regression model was 64·2%.

CONCLUSION

This study determined that for haemodialysis patients, unemployment, increased age, taking more medications or lower exercise frequencies resulted in more severe depression, which translated in turn to higher levels of fatigue. Among all these factors, depression had the greatest impact on the patients' fatigue levels.

RELEVANCE TO CLINICAL PRACTICE

Not only is this finding beneficial to future studies on fatigue as a source of reference, it is also helpful in our understanding of important predictors relating to fatigue in the everyday lives of haemodialysis patients. It is recommended that when caring for fatigued patients, more care should be dedicated to their psychological states, and assistance should be provided in a timely way so as to reduce the amount of fatigue suffered.

Arabic translation, adaptation and modification of the Dialysis Symptom Index for chronic kidney disease stages four and five

BACKGROUND

Symptom burden in chronic kidney disease (CKD) is poorly understood. To date, the majority of research focuses on single symptoms and there is a lack of suitable multidimensional symptom measures. The purpose of this study was to modify, translate, cross-culturally adapt and psychometrically analyse the Dialysis Symptom Index (DSI).

METHODS

The study methods involved four phases: modification, translation, pilot-testing with a bilingual non-CKD sample and then psychometric testing with the target population. Content validity was assessed using an expert panel. Inter-rater agreement, test-retest reliability and Cronbach's alpha coefficient were calculated to demonstrate reliability of the modified DSI. Discriminative and convergent validity were assessed to demonstrate construct validity.

RESULTS

Content validity index during translation was 0.98. In the pilot study with 25 bilingual students a moderate to perfect agreement (Kappa statistic = 0.60-1.00) was found between English and Arabic versions of the modified DSI. The main study recruited 433 patients CKD with stages 4 and 5. The modified DSI was able to discriminate between non-dialysis and dialysis groups (p < 0.001) and demonstrated convergent validity with domains of the Kidney Disease Quality of Life short form. Excellent test-retest and internal consistency (Cronbach's α = 0.91) reliability were also demonstrated.

CONCLUSION

The Arabic version of the modified DSI demonstrated good psychometric properties, measures the multidimensional nature of symptoms and can be used to assess symptom burden at different stages of CKD. The modified instrument, renamed the CKD Symptom Burden Index (CKD-SBI), should encourage greater clinical and research attention to symptom burden in CKD.

Associations of subjective vitality with DNA damage, cardiovascular risk factors and physical performance

AIM

To examine associations of DNA damage, cardiovascular risk factors and physical performance with vitality, in middle-aged men. We also sought to elucidate underlying factors of physical performance by comparing physical performance parameters to DNA damage parameters and cardiovascular risk factors.

METHODS

We studied 2487 participants from the Metropolit cohort of 11 532 men born in 1953 in the Copenhagen Metropolitan area. The vitality level was estimated using the SF-36 vitality scale. Cardiovascular risk factors were determined by body mass index (BMI), and haematological biochemistry tests obtained from non-fasting participants. DNA damage parameters were measured in peripheral blood mononuclear cells (PBMCs) from as many participants as possible from a representative subset of 207 participants.

RESULTS

Vitality was inversely associated with spontaneous DNA breaks (measured by comet assay) (P = 0.046) and BMI (P = 0.002), and positively associated with all of the physical performance parameters (all P < 0.001). Also, we found several associations between physical performance parameters and cardiovascular risk factors. In addition, the load of short telomeres was inversely associated with maximum jump force (P = 0.018), with lowered significance after exclusion of either arthritis sufferers (P = 0.035) or smokers (P = 0.031).

CONCLUSION

Here, we show that self-reported vitality is associated with DNA breaks, BMI and objective (measured) physical performance in a cohort of middle-aged men. Several other associations in this study verify clinical observations in medical practice. In addition, the load of short telomeres may be linked to peak performance in certain musculoskeletal activities.

Home versus in-centre haemodialysis for end-stage kidney disease

BACKGROUND

Home haemodialysis is associated with improved survival and quality of life in uncontrolled studies. However, relative benefits and harms of home versus in-centre haemodialysis in randomised controlled trials (RCTs) are uncertain.

OBJECTIVES

To evaluate the benefits and harms of home haemodialysis versus in-centre haemodialysis in adults with end-stage kidney disease (ESKD).

SEARCH METHODS

The Cochrane Renal Group's Specialised Register was searched up to 31 October 2014.

SELECTION CRITERIA

RCTs of home versus in-centre haemodialysis in adults with ESKD were included.

DATA COLLECTION AND ANALYSIS

Data were extracted by two investigators independently. Study risk of bias and other patient-centred outcomes were extracted. Insufficient data were available to conduct meta-analyses.

MAIN RESULTS

We identified a single cross-over RCT (enrolling 9 participants) that compared home haemodialysis (long hours: 6 to 8 hours, 3 times/week) with in-centre haemodialysis (short hours: 3.5 to 4.5 hours, 3 times/weeks) for 8 weeks in prevalent home haemodialysis patients. Outcome data were limited and not available for the end of the first phase of treatment in this cross-over study which was at risk of bias due to differences in dialysate composition between the two treatment comparisons.Overall, home haemodialysis reduced 24 hour ambulatory blood pressure and improved uraemic symptoms, but increased treatment-related burden of disease and interference in social activities. Insufficient data were available for mortality, hospitalisation or dialysis vascular access complications or treatment durability.

AUTHORS' CONCLUSIONS

Insufficient randomised data were available to determine the effects of home haemodialysis on survival, hospitalisation, and quality of life compared with in-centre haemodialysis. Given the consistently observed benefits of home haemodialysis on quality of life and survival in uncontrolled studies, and the low prevalence of home haemodialysis globally, randomised studies evaluating home haemodialysis would help inform clinical practice and policy.

Relationships between human vitality and mitochondrial respiratory parameters, reactive oxygen species production and dNTP levels in peripheral blood mononuclear cells

Low vitality (a component of fatigue) in middle-aged and older adults is an important complaint often identified as a symptom of a disease state or side effect of a treatment. No studies to date have investigated the potential link between dysfunctional mitochondrial ATP production and low vitality. Therefore, we measured a number of cellular parameters related to mitochondrial activity in peripheral blood mononuclear cells (PBMCs) isolated from middle-aged men, and tested for association with vitality. These parameters estimate mitochondrial respiration, reactive oxygen species (ROS) production, and deoxyribonucleotide (dNTP) balance in PBMCs. The population was drawn from the Metropolit cohort of men born in 1953. Vitality level was estimated from the Medical Outcomes Study Short Form 36 (SF-36) vitality scale. We found that vitality score had no association with any of the mitochondrial respiration parameters. However, vitality score was inversely associated with cellular ROS production and cellular deoxythymidine triphosphate (dTTP) levels and positively associated with deoxycytidine triphosphate (dCTP) levels. We conclude that self-reported persistent low vitality is not associated with specific aspects of mitochondrial oxidative phosphorylation capacity in PBMCs, but may have other underlying cellular dysfunctions that contribute to dNTP imbalance and altered ROS production.

The effect of the physical and mental exercises during hemodialysis on fatigue: a controlled clinical trial

BACKGROUND

Despite regular treatment by hemodialysis, patients on hemodialysis are affected by uremic syndrome, which is marked by fatigue. Fatigue is supposed as the most common and the most severe symptom ever reported by patients with chronic kidney disease.

OBJECTIVES

This controlled study aimed to evaluate the effect of intradialytic physical and mental exercises on fatigue in patients on hemodialysis.

PATIENTS AND METHODS

A total of 66 patients on long-term hemodialysis were selected via purposive sampling and were assigned to two groups, namely, control and experimental groups. The experimental group participated in a intradialytic training program twice a week for two months. The program was designed by a senior expert in physical education. Their fatigue was measured via a fatigue severity scale questionnaire before as well as one and two months after the intervention in both groups.

RESULTS

The mean of the fatigue score within the research units was 42.37. Overall, 42.2% and 56.1% of the participants experienced medium and severe fatigue, respectively. The scores of fatigue decreased significantly from the beginning through two months after intervention in the experiment group.

CONCLUSIONS

With respect to the findings of the study, this method of treatment is recommended due to being cost efficient, easy, applicable, and flexible for alleviating the effect of fatigue on the personal, psychological, and social aspects of life quality in patients on hemodialysis.

Ecological momentary assessment of fatigue, sleepiness, and exhaustion in ESKD

Background

Many patients on maintenance dialysis experience significant sleepiness and fatigue. However, the influence of the hemodialysis (HD) day and circadian rhythms on patients’ symptoms have not been well characterized. We sought to use ecological momentary assessment to evaluate day-to-day and diurnal variability of fatigue, sleepiness, exhaustion and related symptoms in thrice-weekly maintenance HD patients.

Methods

Subjects used a modified cellular phone to access an interactive voice response system that administered the Daytime Insomnia Symptom Scale (DISS). The DISS assessed subjective vitality, mood, and alertness through 19 questions using 7- point Likert scales. Subjects completed the DISS 4 times daily for 7 consecutive days. Factor analysis was conducted and a mean composite score of fatigue-sleepiness-exhaustion was created. Linear mixed regression models (LMM) were used to examine the association of time of day, dialysis day and fatigue, sleepiness, and exhaustion composite scores.

Results

The 55 participants completed 1,252 of 1,540 (81%) possible assessments over the 7 day period. Multiple symptoms related to mood (e.g., feeling sad, feeling tense), cognition (e.g., difficulty concentrating), and fatigue (e.g., exhaustion, feeling sleepy) demonstrated significant daily and diurnal variation, with higher overall symptom scores noted on hemodialysis days and later in the day. In factor analysis, 4 factors explained the majority of the observed variance for DISS symptoms. Fatigue, sleepiness, and exhaustion loaded onto the same factor and were highly intercorrelated. In LMM, mean composite fatigue-sleepiness-exhaustion scores were associated with dialysis day (coefficient and 95% confidence interval [CI] 0.21 [0.02 – 0.39]) and time of day (coefficient and 95% CI 0.33 [0.25 – 0.41]. Observed associations were minimally affected by adjustment for demographics and common confounders.

Conclusions

Maintenance HD patients experience fatigue-sleepiness-exhaustion symptoms that demonstrate significant daily and diurnal variation. The variability in symptoms may contribute to poor symptom awareness by providers and greater misclassification bias of fatigue related symptoms in clinical studies.

Prevalence and correlates of fatigue in chronic kidney disease and end-stage renal disease: are sleep disorders a key to understanding fatigue?

BACKGROUND

Fatigue is an important symptom to patients with advanced chronic kidney disease (CKD). The aim of this study is to examine the prevalence and severity of fatigue among non-dialysis-dependent CKD and end-stage renal disease (ESRD) patients, to examine the association of fatigue with subjective and objective sleep quality, and to identify other modifiable factors associated with fatigue.

METHODS

A cross-sectional survey of 87 non-dialysis-dependent CKD (eGFR ≤45 ml/min/1.73 m(2)) and 86 ESRD patients was done using the Functional Assessment of Chronic Illness Therapy - Fatigue (FACIT-F) and 36-Item Short-Form (SF-36) vitality scale. Higher FACIT-F score denoted less fatigue. Objective sleep was assessed using in-home polysomnography. Predictors of fatigue were determined using a linear regression model.

RESULTS

The mean FACIT-F score among all participants was 34.5 ± 11.0. Mean scores were similar among CKD and ESRD groups (34.25 ± 11.28 vs. 34.73 ± 10.86; p = 0.73). On univariate analyses, patients with higher levels of fatigue were more likely to have cardiovascular disease, benzodiazepine use, depressive symptoms, and slightly lower hemoglobin and serum albumin levels. There was no significant association between severity of sleep apnea and level of fatigue (Apnea Hypopnea Index 20.1 ± 27.6 vs. 20.3 ± 22.0; p = 0.69). Presence of cardiovascular disease, low serum albumin, depressive symptoms, poor subjective sleep quality, excessive daytime sleepiness and restless legs syndrome were independently associated with greater fatigue in multivariable regression models. The FACIT-F score correlated closely with the SF-36 vitality score (r = 0.81, p < 0.0001).

CONCLUSIONS

Patients with advanced CKD and ESRD experience profound fatigue. Depressive symptoms, restless legs syndrome, excessive daytime sleepiness, and low albumin levels may provide targets for interventions to improve fatigue in patients with advanced CKD.

The elderly patient on dialysis: geriatric considerations

The burgeoning population of older dialysis patients presents opportunities to provide personalized care. The older dialysis population has a high burden of chronic health conditions, decrements in quality of life and a high risk of death. In order to address these challenges, this review will recommend routinely establishing prognosis through the use of prediction instruments and communicating these findings to older patients. The challenges to prognosis in adults with end-stage renal disease (ESRD) include the subjective nature of clinical judgment, application of appropriate prognostic tools and communication of findings to patients and caregivers. There are three reasons why we believe these conversations occur infrequently with the dialysis population. First, there have previously been no clinically practical instruments to identify individuals undergoing maintenance hemodialysis (HD) who are at highest risk for death. Second, nephrologists have not been trained to have conversations about prognosis and end-of-life care. Third, other than hospitalizations and accrual of new diagnoses, there are no natural milestone guidelines in place for patients supported by dialysis. The prognosis can be used in shared decision-making to establish goals of care, limits on dialysis support or parameters for withdrawal from dialysis. As older adults with ESRD benefit from kidney transplantation, prognosis can also be used to determine who should be referred for evaluation by a kidney transplant team. The use of prognosis in older adults may determine approaches to optimize well-being and personalize care among older adults ranging from hospice to kidney transplantation.

Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism

Protein energy wasting (PEW) is common in patients with chronic kidney disease (CKD) and is associated with adverse clinical outcomes, especially in individuals receiving maintenance dialysis therapy. A multitude of factors can affect the nutritional and metabolic status of CKD patients requiring a combination of therapeutic maneuvers to prevent or reverse protein and energy depletion. These include optimizing dietary nutrient intake, appropriate treatment of metabolic disturbances such as metabolic acidosis, systemic inflammation, and hormonal deficiencies, and prescribing optimized dialytic regimens. In patients where oral dietary intake from regular meals cannot maintain adequate nutritional status, nutritional supplementation, administered orally, enterally, or parenterally, is shown to be effective in replenishing protein and energy stores. In clinical practice, the advantages of oral nutritional supplements include proven efficacy, safety, and compliance. Anabolic strategies such as anabolic steroids, growth hormone, and exercise, in combination with nutritional supplementation or alone, have been shown to improve protein stores and represent potential additional approaches for the treatment of PEW. Appetite stimulants, anti-inflammatory interventions, and newer anabolic agents are emerging as novel therapies. While numerous epidemiological data suggest that an improvement in biomarkers of nutritional status is associated with improved survival, there are no large randomized clinical trials that have tested the effectiveness of nutritional interventions on mortality and morbidity.

The relationship between psychological factors, inflammation, and nutrition in patients with chronic renal failure undergoing hemodialysis

OBJECTIVE

Hemodialysis has an adverse impact on the immunological, nutritional, and emotional status of patients. The biochemical markers of inflammation and nutrition were studied as well as the relationship of these factors to emotional symptoms.

METHOD

One hundred and ninety-five patients undergoing hemodialysis were enrolled. The mean age was 58.5 years. Emotional symptoms were assessed using the Mini International Neuropsychiatric Interview, Hospital Anxiety and Depression Scale, Chalder Fatigue Scale, and Short-form Health-related Quality of Life. Venus blood was collected for laboratory assessment of serum hemoglobin, albumin, ferritin, C-reactive protein, interleukin (IL) 1beta), IL-6, and tumor necrosis factor alpha.

RESULTS

Among the 195 subjects (92 men and 103 women), 47 (24.1%) fulfilled the criteria for a major depressive disorder (MDD). The IL-6 level in patients with a MDD was significantly higher than in the patients without a MDD. Significant correlation was observed among the following factors: IL-6, fatigue, and quality of life for both physical and mental components. The albumin levels showed a significant correlation with the IL-6 and depression scores.

CONCLUSIONS

These results show that the serum levels of albumin and IL-6 might be laboratory markers associated with the expression of emotional symptoms in patients undergoing hemodialysis. Prospective studies are needed to determine the causal relationships among these variables.

The experience and self-management of fatigue in patients on hemodialysis

Fatigue is a common and debilitating symptom for adult patients with end stage renal disease on hemodialysis, and has been associated with decreased survival and quality of life. Patients on hemodialysis must find ways to manage their fatigue and mitigate its effects on their lives. The purpose of this qualitative descriptive work was to describe the experience and self-management of fatigue in patients on incenter hemodialysis. Several themes were identified which included the nature of fatigue, management of fatigue, consequences of fatigue, and factors associated with fatigue. This information will be valuable to nephrology nurses as they continue to care for and educate patients on hemodialysis.

Effects of 6-times-weekly versus 3-times-weekly hemodialysis on depressive symptoms and self-reported mental health: Frequent Hemodialysis Network (FHN) Trials

BACKGROUND

Patients undergoing maintenance hemodialysis frequently exhibit poor mental health. We studied the effects of frequent in-center and nocturnal hemodialysis on depressive symptoms and self-reported mental health.

STUDY DESIGN

1-year randomized controlled clinical trials.

SETTING & PARTICIPANTS

Hemodialysis centers in the United States and Canada. 332 patients were randomly assigned to frequent (6-times-weekly) compared with conventional (3-times-weekly) hemodialysis in the Frequent Hemodialysis Network (FHN) Daily (n = 245) and Nocturnal (n = 87) Trials.

INTERVENTION

The Daily Trial was a trial of frequent (6-times-weekly) compared with conventional (3-times-weekly) in-center hemodialysis. The Nocturnal Trial assigned patients to either frequent nocturnal (6-times-weekly) hemodialysis or conventional (3-times-weekly) hemodialysis.

OUTCOMES

Self-reported depressive symptoms and mental health.

MEASUREMENTS

Beck Depression Inventory and the mental health composite score and emotional subscale of the RAND 36-Item Health Survey at baseline and 4 and 12 months. The mental health composite score is derived by summarizing these domains of the RAND 36-Item Health Survey: emotional, role emotional, energy/fatigue, and social functioning scales.

RESULTS

In the Daily Trial, participants randomly assigned to frequent compared with conventional in-center hemodialysis showed no significant change over 12 months in adjusted mean Beck Depression Inventory score (-1.9 ± 0.7 vs -0.6 ± 0.7; P = 0.2), but experienced clinically significant improvements in adjusted mean mental health composite (3.7 ± 0.9 vs 0.2 ± 1.0; P = 0.007) and emotional subscale (5.2 ± 1.6 vs -0.3 ± 1.7; P = 0.01) scores. In the Nocturnal Trial, there were no significant changes in the same metrics in participants randomly assigned to nocturnal compared with conventional hemodialysis.

LIMITATIONS

Trial interventions were not blinded.

CONCLUSIONS

Frequent in-center hemodialysis, as compared with conventional in-center hemodialysis, improved self-reported general mental health. Changes in self-reported depressive symptoms were not statistically significant. We were unable to conclude whether nocturnal hemodialysis yielded similar effects.