Differences in quality of life of hemodialysis patients between dialysis centers

A conceptual framework of quality of life in chronic kidney disease in Turkey: A patient-focused approach

This study aimed to determine the quality of life of patients with chronic kidney disease who were receiving dialysis treatment. It also aimed to identify the factors affecting the quality of life of these patients. The independent variables analyzed were: patients' sociodemographic characteristics, organizational characteristics, adherence to treatment, patient-physician relationship, and patient activation level. The sample consisted of 328 patients with chronic kidney disease who received services from dialysis units of two university hospitals and two private dialysis centers. Data analysis was performed through multivariate regression. Results showed that receiving treatment from a hospital-based dialysis unit may have a positive effect in patients' quality of life; and patient-physician relationship, patient activity, and adherence to treatment may positively affect quality of life. Thus, planning of health service delivery that focus on improving the quality of life of patients who are more active by allowing them to establish positive relationships with their physicians and to have a better adherence to treatment should be adopted. These findings may provide health managers, health professionals, and individual patients with evidence-based information about treatment management and health service planning processes related to chronic kidney disease.

The effect of an educational program on quality of life in patients undergoing hemodialysis in western Saudi Arabia

OBJECTIVES

To assess health-related quality of life (QOL) among hemodialysis (HD) patients attending HD units in Jeddah, Saudi Arabia and to evaluate the effect of an educational program on health-related QOL.

METHOD

One hundred HD patients were recruited and followed from 4 different dialysis units in Jeddah, Saudi Arabia between January 2018 and May 2018. The patients were divided into an intervention group (n=50) receiving educational program and control group (n=50). All sociodemographic and laboratory variables were recorded. The QOL short form 36 (SF-36) questionnaire has been used and the score calculated to all patients enrolled in the study before and after educational program. The participants received the educational program in individualized sessions.

RESULTS

The mean ± standard deviation in the intervention group were significantly greater than in controls after the educational program in most dimensions of QOL, including role-physical (35.5 ± 24.7 versus 24.5 ± 23.9, p less than 0.02), role-emotional (58.6 ± 40.1 versus 44.6+43.4, p less than 0.001) and general health (76.6 ± 16 versus 62.9 ± 19.4, p less than 0.001). This reflects high impact of patient counseling in the QOL of HD patients.

CONCLUSION

The scores of health-related quality of life for HD patients were low. The educational program had significant positive impact on all health-related quality of life parameters.

Health-related quality of life compared between kidney transplantation and nocturnal hemodialysis

Background

Health-related quality of life (HRQOL) is an important outcome measure in patients with end-stage renal disease. HRQOL is assumed to improve with kidney transplantation and also with nocturnal hemodialysis compared to conventional hemodialysis. However, there is no evidence regarding HRQOL to support the optimal treatment choice for patients on nocturnal hemodialysis who hesitate opting for transplantation. We therefore compared HRQOL between patients who were treated with kidney transplantation or nocturnal hemodialysis for one year.

Methods

We assessed HQROL using the Kidney Disease Quality of Life–Short Form questionnaire in a cross-sectional sample of patients who were treated with kidney transplantation (n = 41) or nocturnal hemodialysis (n = 31) for one year. All patients on nocturnal hemodialysis were transplantation candidates. Using linear regression, we compared HRQOL between kidney transplantation and nocturnal hemodialysis, and adjusted for age, sex, dialysis duration, cardiovascular disease, and presence of residual urine production.

Results

At one year follow-up, mean age of the study population was 54 ±13 years, and median dialysis duration was 3.2 (IQR 2.1–5.0) years. Kidney transplantation was associated with significantly higher HRQOL on the domain “effects” compared to nocturnal hemodialysis (adjusted difference 12.0 points, 95% CI 3.9; 20.1). There were potentially clinically relevant differences between kidney transplantation and nocturnal hemodialysis on the domains “burden” (adjusted difference 11.1 points, 95% CI -2.6; 24.8), “social support” (adjusted difference 6.2, 95% CI -6.6; 19.1), and the physical composite score (adjusted difference 3.0, 95% CI -2.0; 8.1), but these were not significant.

Conclusions

After kidney transplantation, HRQOL is especially higher on the domain “effects of kidney disease” compared to nocturnal hemodialysis. This can be useful when counseling patients on nocturnal hemodialysis who may opt for transplantation.

Improving Quality of Care in Hemodialysis: a Content Analysis

Introduction: Hemodialysis is currently the most common alternative treatment in patients with renal failure in the world. Today, despite the support provided by healthcare providers for these patients, they still express dissatisfaction with the quality of care and find it inadequate. However, there have been few studies investigating the needs of in-patients receiving hemodialysis care in Iran. Thus this research was undertaken to study the needs and demands of such patients. Methods: This qualitative research was conducted from June to November 2016 to investigate the view points of the patients, their families and health care providers about improving quality of care in dialysis unit. At first, the sampling was based on a purposeful sampling method. A total of 35 participants (patients, their families and health care providers) were interviewed. The interviews were analyzed via Graneheim & Lundman qualitative content analysis. Results: Data analyses led to the production of 700 primary codes, 54 subcategories and 27 secondary categories out which 4 main categories of modification of physical stressors, requirement of support and the requirement of improved quality of Health Care service and improved facilities and equipment requirement. Conclusion: Planning for modification of physical stressors, improved support of patients, enhancing the quality of care services provided by the treatment team, upgrading the facilities and equipment and the adoption of an interdisciplinary approach are all believed to improve the care services among in-patients receiving hemodialysis treatment.

The Relationship Between Dialysis Patients' Quality of Life and Caregivers' Quality of Life

Patients on dialysis require caregiving and assistance in their daily lives from family members and/or others for hospital visitation and supervised administration. This places a considerable burden on caregivers, which can in turn influence caregivers' quality of life (QOL). We recruited dialysis patients and their caregivers to elucidate how the QOL of patients relates to that of their caregivers'. Patients completed the EuroQol 5-Dimension scale (EQ-5D) and Kidney Disease Quality of Life-Short Form. Caregivers completed the EQ-5D and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). We calculated utility index values for the EQ-5D, and physical, mental (MCS), and role-social component summary scores for the SF-36. Compared to national norms, the caregivers of dialysis patients tended to have poor physical health-related QOL but normal mental health-related QOL, as also found with patients. The multivariate analysis revealed that ≥ median dialysis period and ≥ average burden of kidney disease were significantly related to caregiver MCS score (odds ratios; 6.79 and 9.89, respectively). Caregivers tended to have lower physical health-related QOL if their patients had high social QOL, and lower mental health-related QOL during the early stage of the patient's dialysis treatment, and when patients experienced low disease-targeted QOL.

The Effect of Quality of Life on Medication Compliance Among Dialysis Patients

Dialysis treatment is known to lead to reduced quality of life (QOL) among patients. This decreased QOL is believed to influence medication compliance, although this effect has not yet been clarified. In this study, we investigated whether decreased QOL due to dialysis treatment does in fact influence medication compliance. Participants were 92 patients who self-managed their medication and were receiving dialysis treatment at Secomedic Hospital or Chiba Central Medical Center. We surveyed their age, sex, dialysis period, and medication management situation, and administered the EQ-5D and Kidney Disease Quality of Life Instrument-Short Form. A multiple logistic regression analysis with medication compliance as the dependent variable and QOL as the independent variable was conducted. The recovery rate and effective response rate were both 100%. The results indicated that patients with good sleep QOL (mean or above) had higher odds of medication compliance (odds ratio, 3.36; 95% confidence interval, 1.26-8.96; P = 0.016). Therefore, improving the quality of sleep of dialysis patients might help to improve their medication compliance.

Influence of Staff Encouragement on Perceived Burden of Dietary Restriction Among Patients Living Alone

To help relieve the burden of dietary restrictions experienced by many hemodialysis (HD) patients, dialysis staff may encourage patients, with no consideration to the degree of family support. Here, we clarified the effect of staff encouragement and living conditions on the burden of dietary restrictions in HD patients. This retrospective cohort study was conducted using data from the Dialysis Outcomes and Practice Patterns Study (DOPPS) I and III. We enrolled patients aged 18-75 years on HD therapy for at least 3 months. We categorized patients into four groups based on combinations of level of staff encouragement (high or low) and living condition (alone or with family) at baseline survey. Patients who felt they received high staff encouragement and lived with their family were set as the control. The main outcome was increase in patients' perceived burden of dietary restriction after 1 year. 1377 (69.1%) felt they received high staff encouragement, and 176 (9.1%) were living alone. After 1 year, 537 (26.9%) patients reported feeling an increased burden of dietary restriction. A low level of staff encouragement did not increase the burden in any patients, regardless of living situation. However, a high level of staff encouragement did increase the burden in patients living alone (adjusted odds ratio: 1.57, 95% confidence interval: 1.05-2.36). We observed an unexpected association between high staff encouragement and increased burden of dietary restriction among patients living alone. Staff encouragement may not relieve patients' burden with respect to dietary restriction and may in fact exacerbate it.

Nutritional education for management of osteodystrophy: Impact on serum phosphorus, quality of life, and malnutrition

Introduction Osteodystrophy management includes dietary phosphorus restriction, which may limit protein intake, exacerbate malnutrition-inflammation syndrome and mortality among hemodialysis patients. Methods A multicenter randomized controlled trial was conducted in Lebanon, to test the hypothesis that intensive nutrition education focused on phosphorus-to-protein balance will improve patient outcomes. Six hemodialysis units were randomly assigned to the trained hospital dietitian (THD) protocol (210 patients). Six others (184 patients) were divided equally according to the patients' dialysis shifts and assigned to Dedicated Dietitian (DD) and Control protocols. Patients in the THD group received nutrition education from hospital dietitians who were trained by the study team on renal dietetics, but had limited time for hemodialysis patients. Patients in the DD group received individualized nutritional education on dietary phosphorus and protein management for 6 months (2-hour/patient/month) from study renal dietitians. Patients in the control group continued receiving routine care from hospital dietitians who had limited time for these patients and were blinded to the study. Serum phosphorus (mmol/L), malnutrition-inflammation score (MIS), health-related quality of life (HRQOL) index and length of hospital stay (LOS) were assessed at T0 (baseline), T1 (postintervention) and T2 (post6 month follow up). Findings Only the DD protocol significantly improved serum phosphorus (T0:1.78 ± 0.5, T1:1.63 ± 0.46, T2:1.69 ± 0.53), 3 domains of the HRQOL and maintained MIS at T1, but this protective effect resolved at T2. The LOS significantly dropped for all groups. Discussion The presence of competent renal dietitians fully dedicated to hemodialysis units was superior over the other protocols in temporarily improving patient outcomes.

Haemodiafiltration, haemofiltration and haemodialysis for end-stage kidney disease

BACKGROUND

Convective dialysis modalities (haemofiltration (HF), haemodiafiltration (HDF), and acetate-free biofiltration (AFB)) removed excess body fluid across the dialysis membrane with positive pressure and accumulated middle- and larger-size accumulated solutes more efficiently than haemodialysis (HD). This increased larger solute removal combined with use of ultra-pure dialysis fluid in convective dialysis is hypothesised to reduce the frequency and severity of symptoms during dialysis as well as improve clinical outcomes. Convective dialysis therapies (HDF and HF) are associated with lower mortality compared to diffusive therapy (HD) in observational studies. This is an update of a review first published in 2006.

OBJECTIVES

To compare convective (HF, HDF, or AFB) with diffusive (HD) dialysis modalities on clinical outcomes (mortality, major cardiovascular events, hospitalisation and treatment-related adverse events) in men and women with end-stage kidney disease (ESKD).

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register (to 18 February 2015) through contact with a Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

We included randomised controlled trials comparing convective therapy (HF, HDF, AFB) with another convective therapy or diffusive therapy (HD) for treatment of ESKD.

DATA COLLECTION AND ANALYSIS

Two independent authors identified studies, extracted data and assessed study risk of bias. We summarised treatment effects using the random effects model. We reported results as a risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous data together with 95% confidence intervals (CI). We assessed for heterogeneity using the Chi(2) test and explored the amount of variation in treatment estimates beyond that expected by chance using the I(2) statistic.

MAIN RESULTS

Twenty studies comprising 667 participants were included in the 2006 review. In that review, there was insufficient evidence of treatment effects on major clinical outcomes to draw clinically meaningful conclusions. Searching to February 2015 identified 40 eligible studies comprising 3483 participants overall. In total, 35 studies (4039 participants) compared HF, HDF or AFB with HD, three studies (54 participants) compared AFB with HDF, and three studies (129 participants) compared HDF with HF.Risks of bias in all studies were generally high resulting in low confidence in estimated treatment effects. Convective dialysis had no significant effect on all-cause mortality (11 studies, 3396 participants: RR 0.87, 95% CI 0.72 to 1.05; I(2) = 34%), but significantly reduced cardiovascular mortality (6 studies, 2889 participants: RR 0.75, 95% CI 0.61 to 0.92; I(2) = 0%). One study reported no significant effect on rates of nonfatal cardiovascular events (714 participants: RR 1.14, 95% CI 0.86 to 1.50) and two studies showed no significant difference in hospitalisation (2 studies, 1688 participants: RR 1.23, 95% CI 0.93 to 1.63; I(2) = 0%). One study reported rates of hypotension during dialysis were significantly reduced with convective therapy (906 participants: RR 0.72, 95% CI 0.66 to 0.80). Adverse events were not systematically evaluated in most studies and data for health-related quality of life were sparse. Convective therapies significantly reduced predialysis levels of B2 microglobulin (12 studies, 1813 participants: MD -5.55 mg/dL, 95% CI -9.11 to -1.98; I(2) = 94%) and increased dialysis dose (Kt/V urea) (14 studies, 2022 participants: MD 0.07, 95% CI -0.00 to 0.14; I(2) = 90%) compared to diffusive therapy, but results across studies were very heterogeneous. Sensitivity analyses limited to studies comparing HDF with HD showed very similar results. Directly comparative data for differing types of convective dialysis were insufficient to draw conclusions.Studies had important risks of bias leading to low confidence in the summary estimates and were generally limited to patients who had adequate dialysis vascular access.

AUTHORS' CONCLUSIONS

Convective dialysis may reduce cardiovascular but not all-cause mortality and effects on nonfatal cardiovascular events and hospitalisation are inconclusive. However, any treatment benefits of convective dialysis on all patient outcomes including cardiovascular death are unreliable due to limitations in study methods and reporting. Future studies which assess treatment effects of convection dose on patient outcomes including mortality and cardiovascular events would be informative.

Hemodialysis in satellite dialysis units: incidence of patient fallback to the in-center dialysis unit

BACKGROUND

Patient fallbacks occur when a patient treated in a satellite dialysis unit (SDU) must be transferred to an in-center dialysis unit. Fallbacks have an impact on the in-center dialysis unit organization. This study was carried out to estimate the incidence and risk factors of patient fallback.

METHODS

Between 01/01/2006 and 31/12/2010 there were 193 patients starting dialysis in SDUs in one French region. The primary outcome was the incidence of temporary and permanent fallbacks with or without hospitalization. A survival analysis and binomial negative regression were used for the statistical analysis.

RESULTS

Among the 193 patients, 117 (60.6%; 95% confidence interval [CI]: 53.3-67.6) had at least one fallback, which occurred within a median of 249 days (interquartile range [IQR]: 71-469) after the first session in the SDU. The median number of fallbacks by subject was 1 (IQR: 0-4). The median duration of the fallback period was 4 days (IQR: 1-8) and median number of dialysis sessions during the fallback time was 1 (IQR: 1-3). Of the 494 temporary fallbacks, 210 were due to patient hospitalization, the main cause of which was cardiovascular disease. At univariate analysis, patients permanently transferred to in-center hemodialysis units were older, had more peripheral arteriopathy, cancer and arrhythmia. At multivariate analysis, peripheral arteriopathy (relative risk [RR] 2.06, 95% CI 1.05-4.09) and the center (center 2: RR 0.42, 95% CI 0.21-0.84; center 3: RR 2.88, 95% CI 1.20-6.91) were significantly associated with the number of fallbacks.

CONCLUSION

Fallback is a common event in hemodialysis patients treated in SDUs. Yet, the SDU system operates well since a third of patients treated in these units are still in SDUs at 2 years of follow-up. Factors associated with patient fallback are the center and cardiovascular disease.

What have we learned from CONTRAST?

The CONvective TRAnsport STudy (CONTRAST) is a large randomized controlled trial which compared on-line postdilution hemodiafiltration and low-flux hemodialysis in terms of mortality and cardiovascular events. This review summarizes and discusses currently available knowledge acquired by CONTRAST, including the main outcome, comparisons of hemodiafiltration to hemodialysis as well as studies performed in subgroups of CONTRAST.