Quality of life and emotional distress in patients and burden in caregivers: a comparison between assisted peritoneal dialysis and self-care peritoneal dialysis

The Hemodialysis Distress Thermometer for Caregivers (HD-DT-C): development and testing of the psychometric properties of a new tool for screening psychological distress among family caregivers of adults on hemodialysis

PURPOSE

To develop and test the measurement properties of the HD-DT-C, a new tool designed to facilitate the screening of psychological distress and its sources in family caregivers of adults on hemodialysis.

METHODS

The present investigation was carried out in three phases: Phase 1 focused on the process of developing and exploring the content validity and clinical utility of the HD-DT-C using a mixed-methods approach and feedback panels; Phase 2, where the psychometric properties of this new tool were tested in a cross-sectional study (n = 106 caregivers); and Phase 3, where the European Portuguese version of the HD-DT-C was translated and culturally adapted into American English using a forward-backward translation procedure, followed by an expert panel review.

RESULTS

Findings suggested that the HD-DT-C was perceived by feedback panels as practical, appropriate, and useful for increasing dialysis provider/family caregiver communication in nephrology centers. The European Portuguese version of the HD-DT-C showed good test-retest reliability (ICC = 0.991 for the barometer and κ ≥ 0.80 in 77% of the checklist items), high diagnostic accuracy (AUC = 0.956), and strong convergent validity (all r ≥ 0.50) with reference measures that assess quality of life, caregiver burden, and symptoms of anxiety and depression. Cutoff scores with good clinical utility (CUI +  ≥ 0.70) were recommended for screening distress in research (≥ 6) and clinical practice (≥ 5).

CONCLUSION

The HD-DT-C is a brief, reliable, valid, and acceptable measure for identifying self-reported psychological distress and its sources among people caring for a family member or friend on hemodialysis. Future research is needed to explore the measurement properties of the American English version of this new tool.

Effectiveness of mindfulness-based interventions delivered via technology versus therapist among patients on peritoneal dialysis at an outpatient clinic in Singapore

AIMS

This study aimed to (i) evaluate the effectiveness of mindfulness-based interventions in improving self-efficacy, reducing stress and anxiety among peritoneal dialysis patients, and (ii) compare the most effective method of mindfulness based interventions.

METHODS

This randomized three-arm controlled trial recruited first-time peritoneal dialysis patients from the peritoneal dialysis outpatient clinic in Singapore. Patients were randomly allocated to either video-assisted mindfulness training, therapist-assisted mindfulness training or treatment-as-usual. All groups received 4.5 days of structured peritoneal dialysis training at the peritoneal dialysis centre, while video-assisted mindfulness training and therapist-assisted mindfulness training groups were taught additional mindfulness-based techniques. The perceived stress scale, self-efficacy, and anxiety (State and Trait Anxiety Inventory) were measured at baseline, 4- and 12 weeks post-randomization, using reliable and valid instruments.

RESULTS

Thirty-nine patients were recruited (13 in each group). All the therapies showed a significant time trend in anxiety. Only therapist- and video-assisted mindfulness training showed a significant trend in perceived stress scale scores but not treatment-as-usual. All Intervention X Time interactions were not significant. Patients in therapist- and video-assisted mindfulness training groups had reduced perceived stress scale scores compared to treatment-as-usual at week 12.

CONCLUSION

This study demonstrated the potential of mindfulness-based interventions in reducing stress among first-time PD patients.

The effect of renal replacement therapy on health-related quality of life in end-stage renal disease: a meta-analysis

BACKGROUND

End-stage renal disease (ESRD) patients judge health-related quality of life (HRQoL) as an essential outcome. In meta-analysis studies, there is ongoing debate regarding the impact of renal replacement therapy (RRT) methods on HRQoL in ESRD patients. Hence, the main objective of this study was to examine the influence of RRT method utilization on HRQoL in individuals with ESRD. Additionally, the secondary objective was to explore the impact of RRT method use on HRQoL, considering various moderator variables.

METHODS

RRT methods called hemodialysis (HD), peritoneal dialysis (PD), home dialysis (HoD), and kidney transplantation (KT) are used to treat ESRD. HD was defined as in-center HD (ICHD) and home HD (HHD). HoD was defined as HHD and PD. The estimated Hedges' g were conducted by random effect meta-analysis.

RESULTS

A total of 111 publications, including 50.151 patients, were included. KT was better at improving patients' HRQoL than other methods. PD was better at improving patients' HRQoL than HD. HoD was better at improving patients' HRQoL than ICHD. Sensitivity analyses yielded similar results. Publication bias was not tested. The subgroup and meta-regression analyses showed that the moderating variables had a statistically significant effect on the HRQoL of patients with ESRD.

CONCLUSION

For the treatment of ESRD, either KT, PD, or HoD can be used in terms of HRQoL. We need to improve the factors affecting the HRQoL of ESRD patients undergoing HD and ICHD. Healthcare professionals should consider the factors that influence HRQoL and choose an RTT method for each ESRD patient.

Impact of the teach-back method on caregiver outcomes using the "Timing it Right" framework for hemodialysis patients

Background

The caregivers play vital roles in the health care of hemodialysis patients. Ineffective education strategy for the caregivers negatively affects the care ability of caregivers. This study aimed to evaluate the effectiveness of the teach-back method based on the "Timing it Right" framework on the caregivers' care ability, emotions and health-related quality of life for hemodialysis patients.

Methods

The study involved 78 caregivers of 78 hemodialysis patients. Participants in the control group received routine nursing care and traditional oral health education, while those in the intervention group received health education through the teach-back method based on the "Timing it Right" framework. All participants were followed for 6 months. The degree of anxiety and depression of caregivers was evaluated through the Self-rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS), respectively. The care ability of caregivers was assessed by the Family Caregiver Task Inventory (FCTI). The health-related quality of life of hemodialysis patients was evaluated using the 36-item Short Form Health Survey (SF-36).

Results

Compared to baseline (T0), the SAS, SDS and FCTI scores of the intervention group were significantly reduced at the time of discharge (T1), three (T2) and 6 months (T3) (all p < 0.001). Besides, at T1, T2, and T3, the FCTI scores of the intervention group were significantly lower than that in control group (all p < 0.001). The SAS and SDS scores were also significantly lower in the intervention group at T1, T2, and T3 compared to the control group (all p < 0.001). For SF-36 scores, all domains of the intervention group were significantly higher than those of the control group at T1, T2 and T3, including physical functioning (p < 0.001), role physical (p = 0.007), bodily pain (p < 0.001), general health (p = 0.002), vitality (p = 0.043), social functioning (p = 0.016), role emotional (p = 0.002), and mental health(p = 0.025).

Conclusion

The application of teach-back method based on the "Timing it Right" framework could obviously alleviate the anxiety and depression of caregivers for hemodialysis patients. Furthermore, it could significantly improve the care ability of caregivers and the quality of life of patients.

Quality of life of caregivers of end-stage kidney disease patients: Caregivers or care recipients?

BACKGROUND

End-stage kidney disease (ESKD) patients require specific and continuous care, which affects caregivers' quality of life (QOL). It is necessary to define the basic problems and restrictions upon family caregivers of renal patients affecting their physical and psychological status.

OBJECTIVES

The main objectives of this narrative review were to examine the literature over the past 10 years, to describe factors associated with QOL of caregivers of patients with ESKD, and to identify the level of subjective burden reported by caregivers.

METHODS

A literature search was carried out using the following electronic databases: PubMed, Medscape, Science Direct, Scopus, PsychINFO and other scientific sources. Keywords included 'quality of life', 'caregivers', 'end stage kidney or renal disease patients', 'burden' and a combination of these terms. Only studies from January 2010 to December 2020 were included in this study.

RESULTS

The results found that there was significant burden and distress experienced by caregivers that affected their QOL. Patients' QOL is associated with caregivers' QOL. The hours of caring per day and the long-term replacement therapy are associated with great burden.

CONCLUSIONS

More awareness to caregivers' QOL is required to meet their needs, reduce anxiety and to improve patients' QOL. Caregiver support could empower and prepare them for initiation of replacement therapy. This can potentially enhance their diseased family members' QOL and could also restrict the use of health care system resources. Given how difficult it is to conceptualize QOL, a holistic approach to patients and caregivers require QOL assessment in each stage of the kidney disease.

Muslim caregivers' experiences in caring for patients receiving peritoneal dialysis

BACKGROUND

Fulfilling the role of a family caregiver has a substantial effect on the lives of those involved. However, existing information on family caregivers of patients receiving peritoneal dialysis is insufficient-especially Muslim caregivers, whose practice is unique.

OBJECTIVES

The aim of this study was to understand the experiences of Muslim family caregivers looking after patients receiving peritoneal dialysis in an Islamic context.

DESIGN

A descriptive qualitative approach was employed.

PARTICIPANTS

Thirteen Muslim family caregivers who have cared for patients undergoing peritoneal dialysis for at least 1 month.

APPROACH

Data were collected through face-to-face in-depth interviews and a focus group discussion. Content analysis was used to analyse the data with initial codes grouped into sub-categories, generic categories, and main categories.

FINDINGS

The experiences of Muslim family caregivers looking after patients receiving peritoneal dialysis generated two main categories: overwhelmed with suffering and learning to live as a caregiver.

CONCLUSIONS

Caregiving has a substantial impact on Muslim family caregivers. They need to be cared for holistically. The recognition of Islamic beliefs, doctrine of Allah, and religious practices are clear spiritual anchors for caregiving. The findings provide a deeper understanding of the experiences of Muslim family caregivers looking after patients receiving peritoneal dialysis. These findings could serve as the basis for developing a specific nursing intervention for such caregivers.

Burden, depression and anxiety effects on family caregivers of patients with chronic kidney disease in Greece: a comparative study between dialysis modalities and kidney transplantation

INTRODUCTION

Burden of caregivers is a status that was identified as a consequence of daily care. Anxiety and depression are probably related to complex tasks interwined with the care of a family member suffering from chronic kidney disease (CKD).

PURPOSE

To examine the experienced burden, anxiety and depression of Greek caregivers of patients with End-Stage CKD on dialysis as well as kidney transplant recipients (TX) in relation to their demographic profile and to compare among the groups.

METHODS

A total of 396 participants (198 couples of patients and caregivers) were recruited. Structured interviews and self-completed questionnaires were obtained from patients undergoing dialysis modalities as well as TX (28 peritoneal dialysis patients, 137 hemodialysis patients, 33 TX) and their caregivers. Zarit Burden Interview, Beck Depression Inventory and the Generalized Anxiety Disorder-2 scales were used as screening tools.

RESULTS

The majority of caregivers were females (67.2%), with a median age of 58 years. Total burden was indicated as mild to moderate (Mdn = 36 (24-51)). Caregivers of haemodialysis (HD) patients showed the highest burden (Mdn = 40 (26-53)) followed by peritoneal dialysis(PD) (Mdn = 29 (25-51)) and TX group (Mdn = 28 (21-43)) (p = 0.022). Caregivers' depression and anxiety were related to the type of patients' treatment, as well. Caregivers of HD and PD patients reported significantly higher depression (Mdn = 11 (5-18)) and anxiety scores (Mdn = 3 (2-5)) in comparison to TX caregivers (Mdn = 6 (2-13) and Mdn = 2 (2-4)) (p = 0.045 and p = 0.04, respectively).

CONCLUSION

Caregivers of TX patients appeared to have less burden, depression and anxiety levels compared with caregivers of patients on dialysis modalities. Caregivers' burden is significantly associated with anxiety, depressive symptoms, gender, duration of caregiving, educational level, financial status and caregivers' age.

Assessment of Burden in Family Caregivers of Chronic Hemodialysis and Peritoneal Dialysis Patients During the Pandemic Period of COVID-19

INTRODUCTION

In Greece, patients undergoing hemodialysis (HD) usually go to dialysis centers two or three times a week for three/four hours per session because the treatment for home is unavailable; therefore, caregivers should perform supportive transportation and care functions.

PURPOSE

This study was designed to assess the burden and quality of life in caregivers of patients undergoing hemodialysis and peritoneal dialysis (PD) and to record their attitude toward Coronavirus Disease-2019 (COVID-19).

METHODOLOGY

We studied caregivers of patients undergoing hemodialysis and peritoneal dialysis. A total of 80 caregivers took part (30 caregivers of patients of PD and 50 caregivers of patients of HD). The final form of the questionnaire was based on the Quality-of-Life Scale (SF-12) and the Zarit Scale, in order to record the scale of burden and the effect on them throughout the process. The Fear Due to COVID-19 Scale (FCV-19S) contributed to recording the caregivers' fear toward the pandemic of COVID-19.

RESULTS

Most of the caregivers were women with an average age of about 60 years and 6-10 were the patient's wife or partners. The prevalence of the moderate or severe burden of the patients was found at 18.7%, and the few or no burden at all at 33.8%. The prevalence of fear toward COVID-19 was at very high levels, reaching 82.5% in all caregivers.

CONCLUSIONS

During the pandemic period of COVID-19, the role of the caregivers of the patients, both who follow the PD method and those who have joined the HD, is particularly important. Their quality of life has been partially affected in all dimensions.

The availability of support and peritoneal dialysis survival: A cohort study

BACKGROUND

Providing support is important to maintain a patient on peritoneal dialysis (PD), though its impact on outcomes has not been investigated thoroughly. We examined the association between having support and risk of a transfer to hemodialysis.

METHODS

In this retrospective observational cohort study, we used data captured in the Dialysis Measurement Analysis and Reporting system about patients who started PD in Alberta, Canada, between 1 January 2013 and 30 September 2018. Support was defined as the availability of a support person in the home who was able, willing and available to provide support for PD in the patient's residence. The outcome of interest was a transfer to hemodialysis for at least 90 days. We estimated the cumulative incidence of a transfer over time accounting for competing risks and hazard ratios to summarise the association between support and a transfer. We split follow-up time as hazard ratios varied over time.

RESULTS

Six hundred and eighty-three incident PD patients, median age 58 years (IQR: 47-68) and 35% female, were followed for a median of 15 months. The cumulative incidence of a transfer to hemodialysis at 24 months was 26%. Having support was associated with a reduced risk of a transfer between 3 and 12 months after the start of dialysis (HR_3-12mo: 0.44; 95% CI: 0.25-0.78), but not earlier (hazard ratio (HR)_<3mo: 0.96; 95% confidence interval (CI): 0.55-1.69) or later (HR_>12mo: 1.19; 95% CI: 0.65-2.17).

CONCLUSIONS

A transfer to hemodialysis is common. Having a support person at home is associated with a short-term protective effect after the initiation of PD.

Evaluating the feasibility and effectiveness of a mindfulness-based intervention on stress and anxiety of family caregivers managing peritoneal dialysis

Background

Mindfulness-based intervention (MBI) has not been evaluated for its feasibility and effectiveness in reducing stress and anxiety among family caregivers of patients on peritoneal dialysis (PD).

Objectives

(1) To evaluate the feasibility to include MBI during PD training for family caregivers. (2) To determine the effect of MBI on the caregivers’ levels of stress (perceived stress scale, PSS), anxiety state-trait anxiety inventory, STAI), QOL (short-form 36) and reactions to caregiving (caregiver reaction assessment, CRA). (3) To determine differences in the health-related QOL (Kidney Disease Quality of Life Instrument-Short Form, KDQOL PCS and SF-36 MCS) of care recipients with caregivers receiving MBI at 1 month, 3 months and 6 months when compared to those with caregivers receiving routine training. (4) To gather the caregiver’s feedback on the MBI.

Methods

This feasibility study recruited family caregivers to receive either mindfulness training (MT) or treatment-as-usual (TAU) group. Both groups received 4.5-days of structured PD training, but only caregivers in the MT group received 4 days of MT sessions, audio-guided mindfulness practice at home and weekly telephone follow-up.

Results

Forty-four family caregivers participated in this study. Including MBI as part of the PD training was feasible. There was a trend towards lower scores for PSS and T-STAI in the MT group compared to the TAU group. The baseline score of both PSS and T-STAI were positively correlated with post-intervention outcome scores.

Conclusions

Mindfulness-based intervention has the potential to improve psychological symptoms among caregivers of patients with PD.

Comparison of quality of life in end-stage renal disease patients undergoing hemodialysis and peritoneal dialysis in a Moroccan city

PURPOSE

End-stage renal disease patients (ESRD) generally complain about a poor quality of life (QOL). The current study aims to describe and compare ESRD patients' QOL according to dialysis modalities (hemodialysis [HD] and peritoneal dialysis [PD]).

METHODS

This is a cross-sectional study, conducted in dialysis facilities of a Moroccan university hospital, during October 2018. All adult ESRD patients, treated either by HD or PD for more than 3 months and agreeing to participate, were included. Medical data were collected using a questionnaire, whereas the QOL data were collected using the Kidney Disease Quality of Life Short Form (KDQOL SF v 1.3) scale previously validated in dialectal Arabic. The patients' characteristics and QOL data were compared between dialysis modalities (HD vs. PD), using a linear regression, before and after adjustment on several demographic and medical factors as well as a propensity score created to reduce the effect of confounding factors related to the choice of the treatment.

RESULTS

Out of the 91 included patients (50.5% of men, median age 52.0 (IQR [36.5; 62.0]) years), 71 were on HD and 20 were on PD. The highest subscale score, for all participants, was the social support's one with a median of 83.3 (IQR [66.7; 100]), and the lowest one was the kidney disease burden with a median of 25.0 (IQR [0.00; 46.9]). The univariate analysis showed that the Physical Component Score (PCS), the cognitive function, and the dialysis staff encouragement were better in PD patients (p = 0.03, p = 0.04, and p = 0.007, respectively), while the multiple linear regression indicates that the PCS, the dialysis Staff encouragement, and the patient's satisfaction subscores decreased within patients on HD compared with those on PD (p = 0.01, p = 0.03, and p = 0.02, respectively) and that the burden of the kidney disease and the work status subscores increased within patients on HD against those on PD (p = 0.007 and p = 0.04, respectively).

CONCLUSION

This study showed a significant difference between dialysis modalities in some sides of quality of life.

Automated Peritoneal Dialysis: Patient Perspectives and Outcomes

A steadily increasing number of end stage kidney disease (ESKD) patients are maintained on automated peritoneal dialysis (APD) worldwide, in long-standing as well as in more recently established peritoneal dialysis (PD) programs. A better understanding of the technique, paralleled by progress in involved technology, sustained this growth to the point that APD has become the prevalent mode of PD delivery in most high-income countries. While APD is now regarded to be at least as efficient as continuous ambulatory peritoneal dialysis (CAPD) with regard to major biomedical outcomes, its impact on patient-reported outcomes has been less investigated. This paper reviews the main outcomes of APD from a clinical point of view and from the person on dialysis perspective.

Assisted peritoneal dialysis across Europe: Practice variation and factors associated with availability

BACKGROUND

In Europe, the number of elderly end-stage kidney disease patients is increasing. Few of those patients receive peritoneal dialysis (PD), as many cannot perform PD autonomously. Assisted PD programmes are available in most European countries, but the percentage of patients receiving assisted PD varies considerably. Hence, we assessed which factors are associated with the availability of an assisted PD programme at a centre level and whether the availability of this programme is associated with proportion of home dialysis patients.

METHODS

An online survey was sent to healthcare professionals of European nephrology units. After selecting one respondent per centre, the associations were explored by χ ² tests and (ordinal) logistic regression.

RESULTS

In total, 609 respondents completed the survey. Subsequently, 288 respondents from individual centres were identified; 58% worked in a centre with an assisted PD programme. Factors associated with availability of an assisted PD programme were Western European and Scandinavian countries (OR: 5.73; 95% CI: 3.07-10.68), non-academic centres (OR: 2.01; 95% CI: 1.09-3.72) and centres with a dedicated team for education (OR: 2.87; 95% CI: 1.35-6.11). Most Eastern & Central European respondents reported that the proportion of incident and prevalent home dialysis patients was <10% (72% and 63%), while 27% of Scandinavian respondents reported a proportion of >30% for both incident and prevalent home dialysis patients. Availability of an assisted PD programme was associated with a higher incidence (cumulative OR: 1.91; 95% CI: 1.21-3.01) and prevalence (cumulative OR: 2.81; 95% CI: 1.76-4.47) of patients on home dialysis.

CONCLUSIONS

Assisted PD was more commonly offered among non-academic centres with a dedicated team for education across Europe, especially among Western European and Scandinavian countries where higher incidence and prevalence of home dialysis patients was reported.

Difference in perception of advantages and disadvantages of automated peritoneal dialysis for patients undergoing peritoneal dialysis: a conjoint analysis

Background

In Japan, only less than 3% of patients undergoing maintenance dialysis select peritoneal dialysis (PD) as the mode of renal replacement therapy. Half of patients undergoing PD use a cycler for automated PD (APD). However, it remains unclear what patients undergoing PD regard as the benefits of APD. The purpose of this study was to objectively clarify what patients undergoing PD regard as the advantages and disadvantages of APD.

Methods

We designed case simulations that varied according to 6 characteristics of PD, such as the adequacy of dialysis and frequency of bag exchange, and created 16 simulation cards for conjoint analysis. For each case vignette, the respondents were asked to indicate whether they would receive this modality of PD on a 5-point scale.

Results

Thirty-two patients undergoing PD were recruited for this study and completed conjoint analysis simulation questionnaires. The factor with the highest importance in evaluating the modality of PD was the frequency of bag exchange among all participants. When participants were divided into those undergoing APD and continuous ambulatory PD (CAPD), the factor was different between them; that is, the low frequency of bag exchange is regarded as an advantage of APD for patients undergoing APD, while the large-sized cycler device is regarded as a disadvantage of APD for those undergoing CAPD.

Conclusions

The perception of advantages and disadvantages of APD differed between patients undergoing APD and CAPD; the former focus on the frequency of bag exchange, whereas the latter focused the size of device.

Intensity of care and perceived burden among informal caregivers to persons with chronic medical conditions: a systematic review and meta-analysis

PURPOSE

Informal caregivers provide ongoing assistance to a loved one with a health condition. No studies have compared caregiving intensity and perception of burden across chronic medical conditions.

MATERIALS AND METHODS

Databases were searched from inception through 11 September 2020 to identify studies that included the Level of Care Index or the Zarit Burden Inventory (ZBI) among caregivers for people with chronic diseases. Pooled mean ZBI scores and 95% confidence intervals by medical condition were calculated using a random effects model and heterogeneity with I².

RESULTS

Ninety-seven included articles reported on 98 unique samples across 21 chronic diseases. No study used the Level of Care Index. Among 12 disease groups with more than one study, heterogeneity was too high (I² range: 0-99.6%, ≥76.5% in 11 groups) to confidently estimate burden. The percent of studies rated high risk of bias ranged from 0% to 98%, but all external validity items were rated as high-risk in >50% of studies.

CONCLUSIONS

Findings highlight the need for studies on caregiver burden to improve sampling techniques; better report sampling procedures and caregiver and care recipient characteristics; and develop a standard set of outcomes, including a measure of caregiving intensity. Systematic Review Registration: CRD42017080962IMPLICATIONS FOR REHABILITATIONThe amount of burden reported by caregivers to loved ones is associated with reduced physical and mental health.We found considerable heterogeneity in perceived burden reported by informal caregivers across different studies within disease groups, which is likely related to methodological issues, including sampling techniques.Health care providers who use research on caregiver burden should assess how representative study samples may be and exercise caution in drawing conclusions.

Commentary on the NICE guideline on renal replacement therapy and conservative management

NICE Guideline NG107, “Renal replacement therapy and conservative management” (Renal replacement therapy and conservative management (NG107); 2018:1–33) was published in October 2018 and replaced the existing NICE guideline CG125, “Chronic Kidney Disease (Stage 5): peritoneal dialysis” (Chronic kidney disease (stage 5): peritoneal dialysis | Guidance | NICE; 2011) and NICE Technology Appraisal TA48, “Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure”(Guidance on home compared with hospital haemodialysis for patients with end-stage renal failure (Technology appraisal guideline TA48); 2002) The aim of the NICE guideline (NG107) was to provide guidance on renal replacement therapy (RRT), including dialysis, transplant and conservative care, for adults and children with CKD Stages 4 and 5. The guideline is extremely welcomed by the Renal Association and it offers huge value to patients, clinicians, commissioners and key stakeholders. It overlaps and enhances current guidance published by the Renal Association including “Haemodialysis” (Clinical practice guideline: Haemodialysis; 2019) which was updated in 2019 after the publication of the NICE guideline, “Peritoneal Dialysis in Adults and Children” (Clinical practice guideline: peritoneal Dialysis in adults and children; 2017) and “Planning, Initiation & withdrawal of Renal Replacement Therapy” (Clinical practice guideline: planning, initiation and withdrawal of renal replacement therapy; 2014) (at present there are no plans to update this guideline).

There are several strengths to NICE guideline NG107 and we agree with and support the vast majority of recommendation statements in the guideline. This summary from the Renal Association discusses some of the key highlights, controversies, gaps in knowledge and challenges in implementation. Where there is disagreement with a NICE guideline statement, we have highlighted this and a new suggested statement has been written.

Patients undergoing assisted peritoneal dialysis to show a better technique survival: A competing risk analysis

AIMS

To compare patient mortality and technique survival between patients undergoing assisted peritoneal dialysis (aPD) and self-care peritoneal dialysis (sPD).

METHODS

Patients who underwent peritoneal dialysis (PD) at the dialysis center of Second Affiliated Hospital of Soochow University from January 1, 2012 to December 31, 2016, were included and followed to December 31, 2019. Subjects were divided into aPD and sPD groups according to whether the patient could independently complete the PD procedure. Differences in mortality and technique failure rates were compared using competing risk analysis.

RESULTS

A total of 384 patients were included in this study, with 274 patients in the sPD group and 110 patients in the aPD group. The multivariate competing risk regression analysis revealed that age (HR 1.03,95%CI 1.01-1.05, P < .001), aPD (HR 1.84,95%CI 1.10-3.08, P = .02), diabetes (HR 1.51, 95%CI 1.00-2.30, P = .05), residual renal function (HR 0.89, 95%CI 0.82-0.97, P = .005) and serum albumin level (HR 0.92, 95% CI 0.89-0.96, P < .001) were the independent risk factors for mortality. Besides, technique failure in aPD patients was lower than in the sPD group (HR 0.85, 95% CI 0.68-0.97, P = .03).

CONCLUSION

These results found that aPD patients had higher mortality rates but lower technique failure rates than sPD patients. Higher mortality in aPD is probably related to the negative selection of the more comorbid patients. ​ ​.

Quality of life in primary caregivers of patients in peritoneal dialysis and hemodialysis

BACKGROUND

Peritoneal dialysis (PD) is gaining track as an efficient/affordable therapy in poor settings. Yet, there is little data regarding differences in quality of life (QoL) of primary caregivers (PCG) of patients in PD and hemodialysis (HD).

AIM

To compare the QoL of PCG of patients in PD and HD from an upper middle-income population in a Mexican city.

METHODS

Cross-sectional study was carried out with PCG of patients in PD (n=42) and HD (n=95) from 4 hospitals (response rate=70.2%). The SF 36-item QoL questionnaire, the Zarit burden interview, and the Goldberg anxiety/depression scale were used. Mean normalized scores for each QoL domain were compared by dialysis type. Adjusted odds were computed using logistic regression to determine the probability of low QoL (<70% of maximum possible score resulting from the added scores of the 8 dimensions).

RESULTS

The PD group had higher mean scores for emotional role functioning (+10.6; p=0.04), physical functioning (+9.2; p=0.002), bodily pain (+9.2; p=0.07), social functioning (+5.7; p=0.25), and mental health (+1.3; p=0.71); the HD group had higher scores for physical role functioning (+7.9, p=0.14), general health perception (+6.1; p=0.05), and vitality (+3.3; p=0.36). A non-significant OR was seen in multivariate regression (1.51; 95% CI 0.43-5.31). Zarit scores were similar, but workload levels were lower in the PD group (medium/high: PD 7.2%, HD 14.8%). Anxiety (HD 50.5%, PD 19%; p<0.01) and depression (HD 49.5%, PD 16.7%; p<0.01) were also lower in the PD group.

CONCLUSION

Adjusted analysis showed no differences in the probability of low QoL between the groups. These findings add to the value of PD, and strengthen its importance in resource-limited settings.

Burden and Depression among Jordanian Caregivers of Hemodialysis Patients: A Cross-sectional Study

Introduction:

Caring for patients receiving hemodialysis places a burden on caregivers.

Objectives:

To examine caregiving burden and depression in the family caregivers of patients receiving hemodialysis and associated factors.

Methods:

A cross-sectional design was used. Participants were 204 adult caregivers of patients receiving hemodialysis. Questionnaires included sociodemographic characteristics, the Oberst Caregiving Burden Scale-Difficulty (OCBS-D) subscale, Bakas Caregiving Outcomes Scale (BCOS), and the Patient Health Questionnaire-9 to measure the burden and depression of caregivers. Descriptive statistics, two linear regression analyses, and multinomial logistic regression were used in data analysis.

Results:

The majority (59.0%, n = 120) of caregivers had a moderate level of depression with scores ranging from 11 to 16. The analysis showed that the mean score of OCBS-D was 42.0 (SD = 4.7) with scores ranging from 26.9 to 58.9 (range = 32.0), while the caregivers' mean score of BCOS was 52.1 (SD = 9.3) with scores ranging from 38.0 to 82.5 (range = 44.5). Given that the expected score of OCBS-D and BCOS ranged from 15 to 75 and 15 to 105, respectively, the analysis indicated a moderate to a high level of burden among caregivers. Age and travel time were associated with a higher likelihood of negative outcomes in the family caregivers, while higher patient age was associated with a greater caregiver burden.

Relevance to Clinical Practice:

It is important to assess and address the practical issues that caregivers experience, such as employment-related responsibilities, financial difficulties, and the need to learn specific skills related to patients’ chronic illnesses.

Conclusion:

Caregivers of patients receiving hemodialysis are likely to experience moderate depression and burden. Caregiver burden increases with patient age and travel time to the hemodialysis units.

Confirmatory factor analysis and measurement invariance of the English, Mandarin, and Malay versions of the SF-12v2 within a representative sample of the multi-ethnic Singapore population

BACKGROUND

The Short Form Health Survey (SF-12v2) is an increasingly popular measure of health-related quality of life (HRQoL) in Singapore. In order to examine whether the SF-12v2 was appropriate for use in the population, the factor structure and validity of the English, Mandarin, and Malay versions were assessed in a representative sample of the general population of Singapore.

METHODS

6126 respondents were recruited for the Singapore Mental Health Study 2016 (SMHS 2016), a cross-sectional and population-based survey. Confirmatory factor analyses (CFA) were conducted to examine the fit of a two-factor model for the SF-12v2 within a representative sample and amongst the different language (English, Mandarin, Malay) subgroups. Multiple-group CFAs (MGCFA) were conducted to test measurement invariance across the different languages, ethnicities, and chronic illnesses subgroups. CFA-generated latent factor scores (FSCORE command in MPlus) were also compared with the composite scores derived from the developer's scoring method via correlations. Sociodemographic correlates of the latent physical and mental health scores were explored.

RESULTS

CFA results within the full sample supported a two-factor model (RMSEA = 0.044; CFI = 0.991; TLI = 0.988; SRMR = 0.044) in which physical functioning, role physical, bodily pain and general health items loaded onto a latent physical health factor, while role emotional, mental health, social functioning, and vitality items loaded onto a latent mental health factor. Physical and mental health factors were allowed to correlate, unlike the developer's orthogonal scoring method. All standardized loadings were high and statistically significant. Both factors had high internal consistency. CFA within subsamples of English, Mandarin, and Malay languages indicated similar findings. MGCFA results indicate that measurement invariance held across the different languages, ethnicities, and those with and without chronic illnesses.

CONCLUSION

The present study identified a two-factor (physical and mental health) structure within the general population and amongst the three different languages and demonstrated the measurement invariance of SF-12v2 across different subgroups. Findings indicate that algorithm-derived PCS and MCS should be interpreted with caution as they may result in inaccurate conclusions regarding the relationships between HRQoL and its correlates. Future studies using the SF-12v2 within the general population of Singapore should consider utilizing the factor structure put forth in the present study to obtain more appropriate estimates of HRQoL.

Challenges and Opportunities in Expanding Home Hemodialysis for 2025

The Advancing American Kidney Health Initiative has set an aggressive target for home dialysis growth in the United States, and expanding both peritoneal dialysis and home hemodialysis (HHD) will be required. While there has been a growth in HHD across the United States in the last decade, its value in controlling specific risk factors has been underappreciated and as such its appropriate utilization has lagged. Repositioning how nephrologists incorporate HHD as a critical renal replacement therapy will require overcoming a number of barriers. Advancing education of both nephrology trainees and nephrologists in practice, along with increasing patient and family education on the benefits and requirements for HHD, is essential. Implementation of a transitional care unit design coupled with an intensive patient curriculum will increase patient awareness and comfort for HHD; patients on peritoneal dialysis reaching a modality transition point will benefit from Experience the Difference programs acclimating them to HHD. In addition, the potential link between HHD program size and patient outcomes will necessitate an increase in the size of the average HHD program to more consistently deliver quality dialysis results. Addressing the implications of the nursing shortage and need for designing in scope staffing models are necessary to safeguard HHD growth. Seemingly, certain government payment policy changes and physician documentation requirements deserve further examination. Future HHD innovations must result in decreasing the burden of care for HHD patients, optimize the level of device and biometric data flow, facilitate a more functional centralized patient management care approach, and leverage computerized clinical decision support for modality assignment.

Quality of Life in Caregivers of Patients Randomized to Standard- Versus Extended-Hours Hemodialysis

Introduction

Caregivers are essential for the health, safety, and independence of many patients and incur financial and personal cost in this role, including increased burden and lower quality of life (QOL) compared to the general population. Extended-hours hemodialysis may be the preference of some patients, but little is known about its effects on caregivers.

Methods

Forty caregivers of participants of the ACTIVE Dialysis trial, who were randomized to 12 months extended (median 24 hours/wk) or standard (12 hours/wk) hemodialysis, were included. Utility-based QOL was measured by EuroQOL–5 Dimension–3 Level (EQ-5D-3L) and Short Form–6 Dimensions (SF-6D) and health-related QOL (HRQOL) was measured by the 36-Item Short Form Health Survey (SF-36) physical component summary (PCS) and mental component summary (MCS) and the Personal Wellbeing Index (PWI) at enrolment and then every 3 months until the end of the study.

Results

At baseline, utility-based QOL and HRQOL were similar in both groups. At follow-up, caregivers of people randomized to extended-hours dialysis experienced a greater decrease in utility-based QOL measured by EQ-5D-3L compared with caregivers of people randomized to standard hours (–0.18±0.30 vs. –0.02±0.16, P = 0.04). There were no differences between extended- and standard-hours groups in mean change in SF-6D (0.03±0.12 vs. –0.04±0.1, P = 0.8), PCS (–1.2±9.8 vs. –5.6±9.8, P = 0.2), MCS (–4.1±11.2 vs. –0.5±7.1, P = 0.4), and PWI (2.3±17.6 vs. 0.00±20.4, P = 0.9).

Conclusion

Poorer utility-based QOL, as measured by the EQ-5D-3L, was observed in caregivers of patients receiving extended-hours hemodialysis in this small study. Though the findings are exploratory, the possibility that mode of dialysis delivery negatively impacts on caregivers supports the prioritization of research on burden and impact of service delivery in this population.

Social impact of end-stage renal disease requiring hemodialysis among patients with type-2 diabetes and their caregivers in Bengaluru, Karnataka

Introduction:

Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD) requiring hemodialysis. The social impact of a chronic disease like this is far reaching and often difficult to quantify.

Objectives:

To assess the social impact of ESRD among type 2 diabetics requiring hemodialysis and their caregivers.

Methods:

A cross-sectional study was carried out between February 2017 and 18 among patients with type 2 diabetes requiring hemodialysis and their caregivers, attending the dialysis unit at St. John's Medical College Hospital, Bengaluru, India. Social impact was assessed under the domains of stress (physiologic and psychologic), quality of life (QOL), cost of care, self-perceived burden, and caregiver burden. Study tools used were semi-structured interview schedule for sociodemographic data, details regarding diabetes, hemodialysis and cost of care, EuroQol-5D-3L, hemodialysis stressor scale, Cousineau Self-Perceived Burden Scale, and Caregiver Burden Scale.

Results:

A total of 160 participants were included. Majority were males (78%) between 46 and 60 years of age. Most participants experienced moderate stress due to hemodialysis (65%) and moderate self-perceived burden (47.5%). Five (10.6%) participants reported full health, while one (0.6%) reported poor health. Anxiety/depression (80.6%) was the top reported problem among all domains of QOL. Caregiver burden was moderate (53.9%). Annual median cost of direct medical expenditure was ₹258,600 (interquartile range [IQR]: 197,400–433,500) and ₹16,500 (IQR: 9,600–32,100) for nonmedical.

Conclusion:

We conclude that the social impact of ESRD among type 2 diabetics requiring hemodialysis and their caregivers was moderate. Routine counseling of patients receiving haemodialysis and support groups for patients as well as caregivers will help reduce the impact.

Caregiver Burden and Spiritual Well-being in Caregivers of Hemodialysis Patients

The number of hemodialysis patients is increasing worldwide, and the caregivers of these patients experience a great burden. This study was conducted to examine the relationship between caregiver burden and spiritual well-being in caregivers of hemodialysis patients in Kerman, Iran. This correlational study was conducted on 382 caregivers of hemodialysis patients. Data were collected using the Caregiver Burden Inventory (24 items) and Ellison and Paloutzian 20-Item Spiritual Well-being Questionnaire. Data were analyzed by descriptive and inferential statistics (t test, ANOVA, Spearman correlation, and linear regression analysis) in SPSS 20 software. The findings showed that 45 (11.8%) caregivers had mild, 214 (56%) moderate, and 123 (32.2%) high caregiver burden. Furthermore, 1 (0.3%) caregiver had mild, 349 (92.4%) moderate, and 32 (8.4%) high spiritual well-being. Also, Spearman correlation test showed a significant reveres relationship between caregiver burden and spiritual well-being scores (p < 0.001, r = - 0.41). Moreover, the results of the regression analysis showed that the patient's income, frequency of patient dialysis per week, and patient's need to receive care and spiritual well-being were predictors of caregiver burden, which explained 41% of the burden in caregivers. The results of this study revealed that spiritual well-being was negatively related to caregiver burden and was one of its predictors. Therefore, spirituality can be used as a low-cost and effective intervention to reduce the caregiver's burden.

Patient and caregiver perspectives on burnout in peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) can offer patients more autonomy and flexibility compared with in-center hemodialysis (HD). However, burnout - defined as mental, emotional, or physical exhaustion that leads to thoughts of discontinuing PD - is associated with an increased risk of transfer to HD. We aimed to describe the perspectives of burnout among patients on PD and their caregivers.

METHODS

In this focus group study, 81 patients and 45 caregivers participated in 14 focus groups from 9 dialysis units in Australia, Hong Kong, and the United States. Transcripts were analyzed thematically.

RESULTS

We identified two themes. Suffering an unrelenting responsibility contributed to burnout, as patients and caregivers felt overwhelmed by the daily regimen, perceived their life to be coming to a halt, tolerated the PD regimen for survival, and had to bear the burden and uncertainty of what to expect from PD alone. Adapting and building resilience against burnout encompassed establishing a new normal, drawing inspiration and support from family, relying on faith and hope for motivation, and finding meaning in other activities.

CONCLUSIONS

For patients on PD and their caregivers, burnout was intensified by perceiving PD as an unrelenting, isolating responsibility that they had no choice but to endure, even if it held them back from doing other activities in life. More emphasis on developing strategies to adapt and build resilience could prevent or minimize burnout.

Meaning of empowerment in peritoneal dialysis: focus groups with patients and caregivers

BACKGROUND

While peritoneal dialysis (PD) can offer patients more independence and flexibility compared with in-center hemodialysis, managing the ongoing and technically demanding regimen can impose a burden on patients and caregivers. Patient empowerment can strengthen capacity for self-management and improve treatment outcomes. We aimed to describe patients' and caregivers' perspectives on the meaning and role of patient empowerment in PD.

METHODS

Adult patients receiving PD (n = 81) and their caregivers (n = 45), purposively sampled from nine dialysis units in Australia, Hong Kong and the USA, participated in 14 focus groups. Transcripts were thematically analyzed.

RESULTS

We identified six themes: lacking clarity for self-management (limited understanding of rationale behind necessary restrictions, muddled by conflicting information); PD regimen restricting flexibility and freedom (burden in budgeting time, confined to be close to home); strength with supportive relationships (gaining reassurance with practical assistance, comforted by considerate health professionals, supported by family and friends); defying constraints (reclaiming the day, undeterred by treatment, refusing to be defined by illness); regaining lost vitality (enabling physical functioning, restoring energy for life participation); and personal growth through adjustment (building resilience and enabling positive outlook, accepting the dialysis regimen).

CONCLUSIONS

Understanding the rationale behind lifestyle restrictions, practical assistance and family support in managing PD promoted patient empowerment, whereas being constrained in time and capacity for life participation outside the home undermined it. Education, counseling and strategies to minimize the disruption and burden of PD may enhance satisfaction and outcomes in patients requiring PD.

Social Support in the Peritoneal Dialysis Experience: A Qualitative Descriptive Study

Background:

People with end-stage kidney disease can either pursue conservative (palliative) management or kidney replacement therapy. Although transplant is preferred, there is a limited number of organs available rendering the majority of patients treated with some form of dialysis. Hemodialysis and peritoneal dialysis are equivalent regarding clinical outcomes, but peritoneal dialysis is much less costly to provide. Peritoneal dialysis is most often done in the home by the patient or a support person and carries a self-care burden on patients and families. Social support is important for patients receiving peritoneal dialysis and in sustaining peritoneal dialysis therapy. Few studies have comprehensively explored social support in the context of peritoneal dialysis.

Objective:

To explore how patients, family members, and nurses view social support.

Design:

Qualitative, descriptive study.

Setting:

An outpatient peritoneal dialysis clinic in Western Canada.

Participants:

Patients, family members, and nurses.

Methods:

Patients (n = 15), family members (n = 6), and nurses (n = 11) were interviewed between January and May 2018. Content analysis was undertaken using 4 attributes of social support (ie, emotional support, instrumental support, informational support, and appraisal support) as an analytic framework.

Results:

Themes related to the 4 attributes of social support were identified: addressing emotional needs and managing emotion (emotional support); peritoneal dialysis tasks and life tasks (instrumental support); accessing information, receiving information, and learning (informational support); and affirmation/external reassurance and self-confidence (appraisal support). The social support needs of both patients and family members varied and were dependent on their existing support networks and individual perspectives of support.

Limitations:

It is possible that some of the study findings were gender-bound as well as context-specific. The study findings could be different if the patient and caregiver sample were more balanced based on sex. There are also unique attributes of each peritoneal dialysis program that may impact the transferability of these findings to other practice settings.

Conclusion:

Home-based peritoneal dialysis has potential benefit to patients and health care systems. However, receiving peritoneal dialysis requires support. If health care providers wish to promote this treatment, they must also understand how to best support patients and their family members.

Trial Registration:

Not applicable.

Kidney Dyads: Caregiver Burden and Relationship Strain Among Partners of Dialysis and Transplant Patients

BACKGROUND

Caring for dialysis patients is difficult, and this burden often falls on a spouse or cohabiting partner (henceforth referred to as caregiver-partners). At the same time, these caregiver-partners often come forward as potential living kidney donors for their loved ones who are on dialysis (henceforth referred to as patient-partners). Caregiver-partners may experience tangible benefits to their well-being when their patient-partner undergoes transplantation, yet this is seldom formally considered when evaluating caregiver-partners as potential donors.

METHODS

To quantify these potential benefits, we surveyed caregiver-partners of dialysis patients and kidney transplant (KT) recipients (N = 99) at KT evaluation or post-KT. Using validated tools, we assessed relationship satisfaction and caregiver burden before or after their patient-partner's dialysis initiation and before or after their patient-partner's KT.

RESULTS

Caregiver-partners reported increases in specific measures of caregiver burden (P = 0.03) and stress (P = 0.01) and decreases in social life (P = 0.02) and sexual relations (P < 0.01) after their patient-partner initiated dialysis. However, after their patient-partner underwent KT, caregiver-partners reported improvements in specific measures of caregiver burden (P = 0.03), personal time (P < 0.01), social life (P = 0.01), stress (P = 0.02), sexual relations (P < 0.01), and overall quality of life (P = 0.03). These improvements were of sufficient impact that caregiver-partners reported similar levels of caregiver burden after their patient-partner's KT as before their patient-partner initiated dialysis (P = 0.3).

CONCLUSIONS

These benefits in caregiver burden and relationship quality support special consideration for spouses and partners in risk-assessment of potential kidney donors, particularly those with risk profiles slightly exceeding center thresholds.

Quality of Life and Social Support of People on Peritoneal Dialysis: Mixed Methods Research

Although some study has been made into quality of life in patients with peritoneal dialysis, little is known about how this relates to social support. The aim of this paper was to study health-related quality of life, perceived social support and the experiences of people receiving peritoneal dialysis. A cross-sectional study was conducted using quantitative and qualitative methodologies, between June 2015 and March 2017. Fifty-five patients receiving peritoneal dialysis were studied. The most affected quality of life dimensions were the effects of the disease, the burden of the disease, occupational status, sleep and satisfaction. The physical component of the quality of life questionnaire was negatively associated with the number of hospital admissions over the previous year (p = 0.027) and positively associated with social support (p = 0.002). With regard to the mental component, age (p = 0.010) and social support (p = 0.041) were associated with a better quality of life. Peritoneal dialysis, while not a panacea, is experienced as being less aggressive than hemodialysis, allowing greater autonomy and improved perceived health. Greater symptomology corresponded to worse quality of life and to perceiving the disease as a burden. Patients had to adapt to the new situation despite their expectations. Social support was observed to be a key factor in perceived quality of life.

Quality of life improved for patients after starting dialysis but is impaired, initially, for their partners: a multi-centre, longitudinal study

Background

Quality of life (QOL) is important to patients with end stage renal disease and their partners. Despite the first 12 weeks being a critical time in the treatment pathway, limited research exists which examines how the transition onto dialysis impacts QOL. In this study we measured QOL in patients and their partners at pre-dialysis and over the first 12 weeks on dialysis to investigate QOL during this crucial period.

Methods

Patients and their partners, recruited from 10 renal units in England, completed questionnaires at pre-dialysis (n = 166 participants, 83 couples), 6 weeks (n = 90 participants, 45 couples) and 12 weeks (n = 78, 39 couples) after starting dialysis. On each occasion participants completed a QOL questionnaire (WHOQOL-BREF). Multilevel modelling accommodated the nested structure of couples with repeated measures within participants. Three-level random intercept models estimated changes in WHOQOL general QOL and its four domains (Physical, Psychological, Social and Environment). Two-level random intercept models assessed the relationship between baseline clinical and socio-demographic variables with changes in general QOL.

Results

Patients reported positive changes in general QOL from pre-dialysis to 6 weeks (β = 0.42, p < 0.001, 95% CI 0.19, 0.65) and from pre-dialysis to 12 weeks (β = 0.47, p < 0.001, 95% CI 0.24, 0.71). Partners’ general QOL decreased significantly from pre-dialysis to 6 weeks (β = − 0.24, p = 0.04, 95% CI -0.47, − 0.01) but returned to its original level at 12 weeks. Patients reported improvements in the physical domain between pre-dialysis and 12 weeks (β = 6.56, p < 0.004, 95% CI 2.10, 11.03). No other domains changed significantly in patients or partners. Only in patients were there significant associations between moderator variables and general QOL. High comorbidity risk level and diabetes were associated with poorer QOL at pre-dialysis whereas being female and having an arteriovenous fistula were linked with improvements in general QOL.

Conclusions

Patients reported significant improvements in their general and physical QOL after starting dialysis. Partners’ general QOL worsened after patients started dialysis but improved by 12 weeks. Both patients and partners may benefit from additional educational and counselling services in the lead up to, and immediately after starting dialysis, which could facilitate the transition onto dialysis and improve QOL in both.

Study registration

This study was adopted on the NIHR Clinical Research Network (UK). The details of this study are registered on the Research Registry website (www.researchregistry.com). The identifier for this study is researchregistry2574.

A Systematic Review and Jurisdictional Scan of the Evidence Characterizing and Evaluating Assisted Peritoneal Dialysis Models

BACKGROUND AND OBJECTIVES

Compared with hemodialysis, home peritoneal dialysis alleviates the burden of travel, facilitates independence, and is less costly. Physical, cognitive, or psychosocial factors may preclude peritoneal dialysis in otherwise eligible patients. Assisted peritoneal dialysis, where trained personnel assist with home peritoneal dialysis, may be an option, but the optimal model is unknown. The objective of this work is to characterize existing assisted peritoneal dialysis models and synthesize clinical outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A systematic review of MEDLINE, Cochrane Central Register of Controlled Trails, Cochrane Database of Systematic Reviews, Embase, PsycINFO, and CINAHL was conducted (search dates: January 1995-September 2018). A focused gray literature search was also completed, limited to developed nations. Included studies focused on home-based assisted peritoneal dialysis; studies with the assist provided exclusively by unpaid family caregivers were excluded. All outcomes were narratively synthesized; quantitative outcomes were graphically depicted.

RESULTS

We included 34 studies, totaling 46,597 patients, with assisted peritoneal dialysis programs identified in 20 jurisdictions. Two categories emerged for models of assisted peritoneal dialysis on the basis of type of assistance: health care and non-health care professional assistance. Reported outcomes were heterogeneous, ranging from patient-level outcomes of survival, to resource use and transfer to hemodialysis; however, the comparative effect of assisted peritoneal dialysis was unclear. In two qualitative studies examining the patient experience, the maintenance of independence was identified as an important theme.

CONCLUSIONS

Reported outcomes and quality were heterogeneous, and relative efficacy of assisted peritoneal dialysis could not be determined from included studies. Although the patient voice was under-represented, suggestions to improve assisted peritoneal dialysis included using a person-centered model of care, ensuring continuity of nurses providing the peritoneal dialysis assist, and measures to support patient independence. Although attractive elements of assisted peritoneal dialysis are identified, further evidence is needed to connect assisted peritoneal dialysis outcomes with programmatic features and their associated funding models.

Kidney Disease-Specific Scores and Health Utility of Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis Patients and Their Caregivers

OBJECTIVES

This study aimed to compare the EuroQol 5-dimension 5-level questionnaire (EQ-5D-5L), the visual analogue scale (VAS), and the Kidney Disease Quality of Life 36-Item Short-Form Survey (KDQOL-36) scores of Thai continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) patients and to compare the utility scores with the EQ-5D-5L and VAS scores of caregivers.

METHODS

This was a cross-sectional study completed between April 2016 and May 2017. In total, 34 CAPD patients, 30 APD patients, and their caregivers were recruited from a large university hospital in Thailand. A trained interviewer conducted face-to-face interviews. We collected demographic data and used the KDQOL-36 and EuroQol questionnaires (EQ-5D-5L and VAS) to assess the health-related quality of life. Caregivers were asked to assess their own health status using the EQ-5D-5L and VAS.

RESULTS

The EQ-5D-5L and VAS responses of the CAPD and APD patients and their caregivers were not significantly different (P > .05). More than 50% of both patient groups had mobility problems, whereas most patients had no problems with self-care, doing usual activities, pain or discomfort, and anxiety or depression. As for the KDQOL-36, the physical and mental component summaries were not significantly different, and neither were the scores for all of the kidney disease-specific dimensions, including symptoms or problems, effects of kidney disease, and burden of kidney disease (all were P > .05).

CONCLUSIONS

The results indicated that the quality of life of CAPD and APD patients and their caregivers were mostly equivalent. A further longitudinal study of utility score assessments of the differences in modality would be advantageous.

Optimization of Dialysis Modality Transitions for Improved Patient Care

Purpose of review:

Initial and subsequent modality decisions are important, impacting both clinical outcomes and quality of life. Transition from chronic kidney disease to dialysis and between dialysis modalities are periods were patients may be especially vulnerable. Reviewing our current knowledge surrounding these critical periods and identifying areas for future research may allow us to develop dialysis strategies beneficial to patients.

Sources of information:

We searched the electronic database PubMed and queried Google Scholar for English peer-reviewed articles using appropriate keywords (non-exhaustive list): dialysis transitions, peritoneal dialysis, home hemodialysis, integrated care pathway, and health-related quality of life. Primary sources were accessed whenever possible.

Methods:

In this narrative review, we aim to expose the controversies surrounding home-dialysis first strategies and examine the evidence underpinning home-dialysis first strategies as well as home-to-home and home-to-in-center transitions.

Key findings:

Diverse factors must be taken into consideration when choosing initial and subsequent dialysis modalities. Given the limitations of available data (and lack of convincing benefit or detriment of one modality over the other), patient-centered considerations may prime over suspected mortality benefits of one modality or another.

Limitations:

Available data stem almost exclusively from retrospective and observational studies, often using large national and international databases, susceptible to bias. Furthermore, this is a narrative review which takes into account the views and opinions of the authors, especially as it pertains to optimal dialysis pathways.

Implications:

Emphasis must be placed on individual patient goals and preferences during modality selection while planning ahead to achieve timely and appropriate transitions limiting discomfort and anxiety for patients. Further research is required to ascertain specific interventions which may be beneficial to patients.

Health-related quality of life as predictor of mortality in end-stage renal disease patients: an observational study

Background

Health-related quality of life (HRQoL) is an important component of patient-centered outcomes and a useful parameter for monitoring quality of care. We assessed HRQoL, its determinants, and associations with mortality in patients with end-stage renal disease (ESRD).

Methods

Short Form-36 was used to assess HRQoL, its domain components, and physical (PCS) and mental (MCS) composite summary scores in altogether 400 (338 incident and 62 prevalent) dialysis patients with median age 64 years, 37% women, 24% diabetes mellitus (DM), 49% cardiovascular disease (CVD), and median estimated glomerular filtration rate (eGFR) of 5.3 (3.0–9.4) ml/min/1.73². Results were analyzed separately for 338 incident patients starting on hemodialysis (HD; 68%) or peritoneal dialysis (PD; 32%), and 62 prevalent PD patients. Mortality risk was analyzed during up to 60 months (median 28 months).

Results

Linear multivariate regression analysis showed that in incident dialysis patients, 1-SD higher PCS associated negatively with 1-SD higher age, DM and CVD, and positively with 1-SD higher hemoglobin and sodium (adjusted r² = 0.17). In 62 prevalent PD patients, 1-SD higher PCS was negatively associated with 1-SD higher age. MCS was not associated to any of the investigated factors. Multivariate Cox regression analysis showed that in incident dialysis patients, 1-SD increase of PCS associated with lower all-cause mortality, hazard ratio 0.65 (95% confidence interval 0.52–0.81), after adjustments for age, sex, DM, CVD, plasma albumin, C-reactive protein and eGFR whereas 1-SD lower MCS did not associate with mortality. In PD patients, neither PCS nor MCS associated with mortality.

Conclusions

MCS did not associate with any of the investigated clinical factors, whereas lower PCS associated with higher age, CVD, DM, and lower hemoglobin and sodium levels. MCS was not associated with mortality, whereas lower PCS associated with increased mortality risk. These results suggest that HRQoL - in addition to its role as patient-centered outcome - matters also for hard clinical outcomes in ESRD patients. Our knowledge about factors influencing MCS in ESRD patients is limited and should motivate further studies.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1318-x) contains supplementary material, which is available to authorized users.

Longitudinal Trends in Quality of Life and Physical Function in Frail Older Dialysis Patients: A Comparison of Assisted Peritoneal Dialysis and In-Center Hemodialysis

Background

In-center hemodialysis (HD) has been the standard treatment for older dialysis patients, but reports suggest an associated decline in physical and cognitive function. Cross-sectional data suggest that assisted peritoneal dialysis (aPD), an alternative treatment, is associated with quality of life (QoL) outcomes that are comparable to in-center HD. We compared longitudinal changes in QoL between modalities.

Methods

We enrolled 106 aPD patients, matched with 100 HD patients from 20 renal centers in England and Northern Ireland. Patients were assessed quarterly for 2 years using the Hospital Anxiety and Depression Scale (HADS), SF-12 physical and mental scores, symptom score, Illness Intrusiveness Rating Scale (IIRS), Barthel's score, and the Renal Treatment Satisfaction Questionnaire (RTSQ). Mixed model analysis was used to assess the impact of dialysis modality on these outcomes during follow-up. P values were adjusted for multiple significance testing.

Results

Multivariate analysis showed no difference in any of the outcome measures between aPD and HD. Longitudinal trends in outcomes were also not significantly different. Higher age at baseline was associated with lower IIRS and RTSQ scores during follow-up. One-hundred and twenty-five (60.6%) patients dropped out of the study: 59 (28.6%) died, 61 (29.6%) withdrew during follow-up, and 5 (2.5%) were transplanted.

Conclusions

Quality of life outcomes in frail older aPD patients were equivalent to those receiving in-center HD. Assisted PD is thus a valid alternative to HD for older people with end-stage kidney disease (ESKD) wishing to dialyze at home.

Evaluating Burden and Quality of Life among Caregivers of Patients Receiving Peritoneal Dialysis

Peritoneal dialysis (PD) is advocated as treatment of choice for most end-stage renal disease (ESRD) patients, including elderly and frail patients. It typically requires caregiver involvement to support care at home. The purpose of this study was to examine changes in burden and quality of life (QOL) in caregivers of prevalent PD patients over 12 months. Data were collected in 44 caregivers of PD patients (mean age 38.4 ± 6.3 years; 60% female) in Singapore at baseline and 12 months. Measures included demographics, the Lay Care-Giving for Adults Receiving Dialysis (LC-GAD), Zarit Burden Interview (ZBI), and the World Health Organization Quality of Life instrument (WHOQOL-BREF). Paired t-tests indicate a significant decrease in task-related aspects of caregiving ( p = 0.04), particularly in relation to personal hygiene ( p < 0.01), over time. Cognitive aspects of caregiving remained unchanged. Perceived burden, however, significantly increased ( p < 0.01), with significantly more caregivers reporting moderate to severe caregiver burden at follow-up (28%) relative to baseline (13%; p < 0.01). There was a significant reduction in psychological health (under WHOQOL) ( p = 0.01). Study findings indicate an increase in caregiver burden and a reduction in psychological health despite a reduction in task-related aspects of caregiving, supporting a further exploration of the “wear-and-tear” hypothesis among this population. Intervention strategies are needed.

Burden, coping mechanisms, and quality of life among caregivers of hemodialysis and peritoneal dialysis undergoing and renal transplant patients

CONTEXT

Investigations on burden, coping, and quality of life (QOL) in caregivers of hemodialysis (HD) and peritoneal dialysis (PD) undergoing and renal transplant (RT) patients may lead to the well-being of caregivers, and these studies are sparse and nil in Indian context.

AIM

This study aims to comparatively evaluate the burden, coping mechanisms, and QOL among caregivers of HD and PD undergoing and RT patients.

SETTING AND DESIGN

Tertiary care hospital, cross-sectional and descriptive study.

SUBJECTS AND METHODS

Burden, coping mechanisms, and QOL in caregivers of HD and PD undergoing and RT patients were investigated using Zarit burden interview, revised ways of coping and short-form 36 in 30 each caregivers of HD and PD undergoing and RT patients.

RESULTS

Moderate to severe burden, mild to moderate burden, and no burden were observed in the majority of caregivers of HD and PD undergoing and RT patients. Significantly higher mean burden score in caregivers of HD undergoing than RT patients (P < 0.01); accepting responsibility in caregivers of RT than PD undergoing patients; social functioning in caregivers of HD than PD undergoing patients; and general health in caregivers of RT than HD undergoing patients, was observed. Lower physical component was common in each group, whereas accepting responsibility in HD, self-controlling in PD, and age and escape avoidance in RT were found to be the specific predictors of the burden score.

CONCLUSIONS

Caregivers of HD and PD undergoing and RT patients have different levels of burden, use different mechanisms to cope, and showed different predictors of burden score.

Health-related quality of life in peritoneal dialysis patients: A narrative review

Health-related quality of life (HRQOL) is an important aspect of patients´ health that should be an integral part of the evaluation of patient-centered outcomes, not least because HRQOL associates with patients´ morbidity and mortality. This applies also to chronic kidney disease patients, including those dependent on renal replacement therapies, the type of which may influence patients´ perception of HRQOL. Several studies have addressed HRQOL in chronic kidney disease patients undergoing renal replacement therapies, especially transplanted patients and hemodialysis patients, while publications concerning peritoneal dialysis (PD) patients are scarcer. This review describes some of the methods used to assess HRQOL, factors influencing HRQOL in PD patients, HRQOL in PD vs hemodialysis, and the relation between HRQOL and patient outcomes. We conclude that assessment of HRQOL-often neglected at present-should be included as a standard measure of patient-centered outcomes and when monitoring the quality and effectiveness of renal care including PD treatment.

Burden of Care and Quality of Life Among Caregivers for Adults Receiving Maintenance Dialysis: A Systematic Review

RATIONALE & OBJECTIVE

Dialysis is a burdensome and complex treatment for which many recipients require support from caregivers. The impact of caring for people dependent on dialysis on the quality of life of the caregivers has been incompletely characterized.

STUDY DESIGN

Systematic review of quantitative studies of quality of life and burden to caregivers.

SETTING & STUDY POPULATION

Caregivers of adults receiving maintenance dialysis.

SELECTION CRITERIA FOR STUDIES

The Cochrane Library, Embase, PsycINFO, CINAHL, PubMed, and MEDLINE were systematically searched from inception until December 2016 for quantitative studies of caregivers. Pediatric and non-English language studies were excluded. Study quality was assessed using a modified Newcastle-Ottawa scale.

DATA EXTRACTION

2 independent reviewers selected studies and extracted data using a prespecified extraction instrument.

ANALYTICAL APPROACH

Descriptive reports of demographics, measurement scales, and outcomes. Quantitative meta-analysis using random effects when possible.

RESULTS

61 studies were identified that included 5,367 caregivers from 21 countries and assessed the impact on caregivers using 70 different scales. Most (85%) studies were cross-sectional. The largest identified group of caregivers was female spouses who cared for recipients of facility-based hemodialysis (72.3%) or peritoneal dialysis (20.6%). Caregiver quality of life was poorer than in the general population, mostly comparable with caregivers of people with other chronic diseases, and often better than experienced by the dialysis patients cared for. Caregiver quality of life was comparable across dialysis modalities.

LIMITATIONS

Heterogeneity in study design and outcome measures made comparisons between studies difficult and precluded quantitative meta-analysis. Study quality was generally poor.

CONCLUSIONS

Quality of life of caregivers of dialysis recipients is poorer than in the general population and comparable to that of caregivers of individuals with other chronic diseases. The impact of caring for recipients of home hemodialysis or changes in the impact of caring over time have not been well studied. Further research is needed to optimally inform dialysis programs how to educate and support caregivers.

Health-Related Quality of Life in Patients Treated with Continuous Ambulatory Peritoneal Dialysis and Automated Peritoneal Dialysis in Singapore

OBJECTIVE

This study aimed to compare the health-related quality of life (HRQOL) in patients with end-stage renal disease (ESRD) treated with continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) in Singapore.

METHODS

The data used in this study were from two cross-sectional surveys of ESRD patients. HRQOL was assessed using the Kidney Disease Quality of Life (KDQOL) instrument. Socio-demographic characteristics and clinical data were collected. The physical component summary (PCS) and mental component summary (MCS) scores, kidney disease component summary (KDCS) score and its three scales (symptoms, effects, burden), and one health utility score [EuroQol 5-dimension (EQ-5D)] were calculated and compared between CAPD and APD using multivariate linear regression.

RESULTS

In total, 266 patients were included, with 145 on CAPD (mean age 60.8 years) and 121 on APD (mean age 57.4 years). After adjustment for all variables collected, APD patients had significant higher scores in PCS and KDQOL symptoms than CAPD patients, suggesting that APD was associated with better physical health and milder dialysis-related symptoms.

CONCLUSION

The HRQOL of CAPD and APD patients was largely equivalent in Singapore, but APD patients seemed to experience better physical health and be less bothered by dialysis-related symptoms.

Anxiety and depression in patients with end-stage renal disease: impact and management challenges - a narrative review

Psychiatric disorders commonly co-exist with the diagnosis of chronic kidney disease (CKD). Research on depression and CKD has increased to a great extent. Multiple studies have demonstrated that depression is more prevalent in CKD and that end-stage renal disease is a robust risk factor for adverse outcomes such as hospitalization and mortality, yet these are often underdiagnosed or untreated. This review provides a selective overview on the prevalence rates of depression and anxiety in patients with CKD and across renal replacement therapies, the factors most consistently associated with symptoms of distress and their clinical implications. Finally, treatment and management strategies from relevant literature are appraised and discussed.

Experiences of Living with Assisted Peritoneal Dialysis - A Qualitative Study

BACKGROUND

People's experiences of living with assisted peritoneal dialysis (aPD) have not been studied previously. Assisted PD is successfully used as renal replacement therapy for elderly and disabled patients with end-stage renal disease. To be treated with aPD implies being dependent on lifelong treatment at home. The aim of this study was to explore adults' experiences of living with aPD.

METHODS

In-depth interviews were conducted with 10 participants with aPD, median age 82.5 years. The text was analyzed using a phenomenological-hermeneutical method.

RESULTS

The participants experienced limitations and an uncertain future, but through different strategies and participation in healthcare, they could still enjoy what was important in life for them. The analysis of the text resulted in 4 main themes; 1) Facing new demands, 2) Managing daily life, 3) Partnership in care, and 4) Experiencing a meaningful life, leading to the comprehensive understanding: 'Striving for maintaining wellbeing'.

CONCLUSION

The participants expressed that they experienced a good quality of life despite being physically frail, severely ill, and in need of home-based lifesaving treatment. The findings suggest that aPD should be available everywhere where PD is offered. Integrating the model of person-centered care may greatly improve the care for persons living with aPD.

Family Caregiving in Japan: The Influence of Cultural Constructs in the Care of Adults With Cancer

Caring culture is a concept embodying the perceptions and caring practices of caregivers, acknowledging the unique role of cultural beliefs in shaping behavior. A qualitative descriptive study with 13 caregivers of adult family members with a cancer diagnosis in Japan was conducted to gain insight into perceptions and experiences surrounding caregiving. Several major categories were identified, representing rarely reported cultural constructs of high cultural value for the Japanese: On-repayment for what the patient has given, Caregiving as performing a socially expected role, Enryo/meiwaku-restraint in asking for help, Family decision making reflecting strong bonds, Omoiyari-empathizing with the patient's feelings, and Inori-praying to myriad gods and ancestors. The Japanese cultural construct of ie (the strong relationship to family lineage and spiritual connection to past and future generations) is helpful in understanding these categories. Invisible yet powerful cultural constructs permeated caregiving practices. Insights from Japanese cultural concepts and beliefs may foster sensitivity and individualized care in diverse settings, cultures, and societies.

Managing multiple chronic conditions in Singapore - Exploring the perspectives and experiences of family caregivers of patients with diabetes and end stage renal disease on haemodialysis

OBJECTIVE

Diabetes mellitus (DM) is the commonest cause of end stage renal disease (ESRD). Despite increasing DM-ESRD prevalence and high dependency on care, there is a lack of literature on DM-ESRD caregivers. We sought to explore the perspectives and experiences of caregivers of patients with DM undergoing haemodialysis in Singapore.

DESIGN

This study employed an exploratory, qualitative design comprising in-depth interviews with caregivers of DM-ESRD patients.

METHODS

Semi-structured interviews were conducted with a sample of 20 family caregivers (54.2 ± 12.6 years; 75% female) of DM-ESRD patients. Data were analysed using Thematic Analysis.

RESULTS

Key caregiving challenges identified were managing diet, care recipients' emotions and mobility dependence. Patients' emotional reactions caused interpersonal conflicts and hindered treatment management. Difficulties in dietary management were linked to patients' erratic appetite, caregivers' lack/poor understanding of the dietary guidelines and caregivers' low perceived competence. Limited resources in terms of social support and finances were also noted. Physical and psychological well-being and employment were adversely affected by caregiving role.

CONCLUSION

This study highlights distinctive aspects of the DM-ESRD caregiving experience, which impact on caregivers' health and challenge care. Disease management programmes should be expanded to support caregivers in dealing with multimorbidity.