Sources of Distress Experienced by Parents of Children with Chronic Kidney Disease on Dialysis: A Qualitative Systematic Review

Identifying experiences of supportive care of children and young people affected by kidney failure: A qualitative systematic review

BACKGROUND

Children and young people affected by kidney failure experience complexities in their care. Little is known about the unique needs of this young patient population group living with a long-term condition.

OBJECTIVE

A meta-aggregation of all qualitative studies was conducted to identify experiences of supportive care among children and young people living with kidney failure.

METHODS

A systematic review of qualitative studies was conducted following the Joanna Briggs Institute meta-aggregation method. This review has been reported according to the PRISMA statement guidelines. Six electronic databases (CINAHL, Cochrane Library, MEDLINE, Proquest, PsycINFO, and Scopus) were comprehensively searched by an expert systematic review librarian using keywords and subject headings, from inception to September 2022. All studies were accessed using a predetermined inclusion and exclusion criteria. Methodological quality assessment and data extraction performed. Qualitative findings accompanied by illustrative quotes from included studies were extracted and grouped into categories which created the overall synthesised findings.

RESULTS

A total of 34 studies were included in this review representing a total of 613 children and young people affected by kidney failure. There was a total of 190 findings which created 13 categories representing experiences of supportive care. The meta-aggregation developed five synthesised findings namely: 'physical needs', 'information and technology', 'treatment and healthcare', 'social needs' and 'psychological impacts'.

CONCLUSION

This systematic review identified that children and young people affected by kidney failure can experience a range of unmet supportive care needs in routine clinical services. Kidney failure impacted children and young people's self-identify, social and peer networks, introduced daily practical needs because of inherent physical and psychological burden due to the failure and associated treatments. Despite improvements in the medical management of kidney failure in children and young people, further attention is needed to optimise supported self-management in this young patient group.

A qualitative study on the experiences of family caregivers of children with End Stage Kidney Disease (ESKD)

BACKGROUND

Family caregivers, mostly parents, are greatly involved in the care of their children with end stage kidney disease (ESKD) globally. Yet, the experiences of these caregivers and the demands placed on them by the caregiving role have not been explored or documented in Ghana. This study explored how caregiving affects the psychological, physical, social, and spiritual well-being of family caregivers of children with end stage kidney disease (ESKD) in Ghana.

METHODS

A phenomenological approach with the purposive sampling technique was used to gather data from 12 family caregivers of children with ESKD at a pediatric renal unit in Ghana. A semi-structured interview guide was constructed based on the constructs of the City of Hope Quality of Life (QoL) Family Caregiver Model and the research objectives. Colaizzi's thematic analysis approach was utilized to analyze data for this study. Themes were organized under the domains of the chosen model, and a new theme outside these domains was also generated.

RESULTS

The majority of the family caregivers experienced anxiety, fear, uncertainty, and hopelessness in response to the children's diagnosis and care. The thought of the possibility of the children dying was deeply traumatizing for our participants. Most participants reported bodily pains and physical ailments because of lifting and caring for the children. Financial constraint was also a key issue for all the family caregivers. Most of them received diverse support from their families and loved ones. Due to the demanding nature of the care, most family caregivers had to change or quit their jobs. They coped with the challenges through prayers, participating in religious activities, and being hopeful in God for healing.

CONCLUSION

All the family caregivers had their psychological well-being compromised as a result of the challenges they encountered physically, socially, and spiritually. Continuous psychosocial support, funding support, and review of policies on leave for civil workers with children diagnosed with ESKD are urgently required.

Catastrophic healthcare expenditure and caregiver burden in pediatric chronic kidney disease - a mixed methods study from a low resource setting

BACKGROUND

Caregivers of children with chronic kidney disease (CKD) in low resource settings must provide complex medical care at home while being burdened by treatment costs often paid out-of-pocket. We hypothesize that caregiver burden in our low resource setting is greater than reported from high income countries and is associated with frequent catastrophic healthcare expenditure (CHE).

METHODS

We conducted a mixed-methods study of primary caregivers of children with advanced CKD (stage 3b-5) in our private-sector referral hospital in a low resource setting. We assessed caregiver burden using the Pediatric Renal Caregiver Burden Scale (PRCBS) and measured financial burden by calculating the proportion of caregivers who experienced CHE (monthly out-of-pocket healthcare expenditure exceeding 10% of total household monthly expenditure). We performed a qualitative reflexive thematic analysis of caregiver interviews to explore sources of burden.

RESULTS

Of the 45 caregivers included, 35 (78%) had children on maintenance dialysis (25 PD, 10 HD). Mean caregiver burden score was 141 (± 17), greater than previously reported. On comparative analysis, PRCBS scores were higher among caregivers of children with kidney failure (p = 0.005), recent hospitalization (p = 0.03), non-earning caregivers (p = 0.02), caring for > 2 dependents (p = 0.009), and with high medical expenditure (p = 0.006). CHE occurred in 43 (96%) caregivers of whom 37 (82%) paid out-of-pocket. The main themes derived relating to caregiver burden were severe financial burden, mental stress and isolation, and perpetual burden of concern.

CONCLUSION

Parents of children with CKD experienced severe caregiver burden with frequent CHE and relentless financial stress indicating an imminent need for social support interventions.

Palliative Care Training in Pediatric Nephrology Fellowship: A Cross-Sectional Survey

Key Points

Pediatric nephrology fellows have limited primary palliative exposure and opportunities to develop and refine primary palliative care (PC) skills. While experiential practice seems to improve confidence, most fellows have low confidence to provide primary PC. Fellows indicate a need and desire for additional PC training during nephrology fellowship.

Background

Children with CKD and their families encounter significant burdens. Integrating primary palliative care (PC), holistic care provided by nephrologists focused on enhancing quality of life through symptom management, stress relief, and high-quality serious illness communication, provides an opportunity to promote flourishing. Incorporation of primary PC education in training is therefore recommended. Yet, adult nephrology fellows report inadequate preparation to deliver primary PC. Similar experience of pediatric nephrology fellows is unknown. We sought to describe pediatric nephrology fellows' experience in providing primary PC and PC exposure during training.

Methods

We administered a cross-sectional web-based survey to pediatric nephrology fellows associated with the American Society of Pediatric Nephrology listserv in May 2021. The survey was adapted from a previously validated instrument and pretested by stakeholder nephrologists and subspecialty PC physicians; queries included institutional and personal PC experience, training, and confidence in primary PC delivery. Data were summarized descriptively.

Results

Response rate was 32% (32/101). Respondents were 81% female and 50% White; 87% practiced in an urban setting. Only one fellow (3%) completed a PC rotation during fellowship, and 15 respondents (48%) completed a rotation in medical school or residency. Fellows reported substantially more practice conducting kidney biopsies than family meetings; 68% of fellows had performed >10 kidney biopsies, and 3% of fellows had led >10 family meetings. Confidence in navigating challenging communication, addressing psychological distress, or managing physical symptoms associated with CKD was generally low. Fellows with greater exposure to family meetings reported more confidence navigating challenging communication. Fellows endorsed a need for additional training; 97% indicated that training should happen during fellowship.

Conclusions

Few pediatric nephrology fellows receive PC education or exposure during training, resulting in low rates of knowledge and confidence in primary PC delivery. Fellows indicate a need and desire for improved PC training.

A qualitative study on hope in iranian end stage renal disease patients undergoing hemodialysis

BACKGROUND

End Stage Renal Disease (ESRD) patients undergoing hemodialysis are faced with serious problems in their lives. Hope, as a multifaceted factor, plays a critical role in these patients' lives. Given the multifaceted process of hope, this study aimed to describe hope and identify the challenges, strategies, and outcomes of hope in Iranian ESRD patients undergoing hemodialysis.

METHODS

This is a qualitative study using content analysis. The participants were selected using purposive sampling. The data were collected using deep, semi-structured interviews with 14 participants; it continued until reaching data saturation. Graneheim and Lundman content analysis approach was used to analyze the data.

RESULTS

Five main categories and twenty-two subcategories emerged; the categories consisted of (1) Hope described as a particular event to happen, (2) Opportunities and threats to achieve hope, (3) Negative emotions as barriers to achieve hope, (4) Positive coping strategies to achieve hope, and (5) Growth and excellence as the outcomes of hope.

CONCLUSIONS

Based on the findings, ESRD patients undergoing hemodialysis described hope as a positive feeling of expectation and desire for a special thing to happen. They faced threats and opportunities to achieve hope, which exposed them to negative emotions as barriers of hope. Thus, they make use of positive coping strategies to achieve hope. Moreover, hope led to growth and excellence. Through awareness of hope, definition and strategies to achieve it, and teaching them, physicians and nurses working in hemodialysis wards can enhance hope in patients.

Predicting psychosocial risk in pediatric kidney transplantation: An exploratory cluster analysis of a revised Pediatric Transplant Rating Instrument

BACKGROUND

The Pediatric Transplant Rating Instrument (P-TRI) is a 17-item scale developed to assess psychosocial risk factors for poor outcomes after solid organ transplantation. Research has identified the limitations of the original instrument and proposed revisions to improve clinical utility. This project examined patterns of risk in children being evaluated for kidney transplant using a revised P-TRI.

METHODS

A multidisciplinary kidney transplant team revised the P-TRI. A social worker and a psychologist collaboratively completed the modified instrument for 37 children after the psychosocial pretransplant evaluation. Electronic medical records were reviewed for transplant status (transplanted, active waitlist, inactive) 1 year later. Exploratory cluster analyses and chi-square tests examined patterns of risk and correlates with cluster membership.

RESULTS

Three clusters were identified. The high-risk group (29.7%) had difficulties with medication and appointment adherence, strained relationships with the medical team, and the presence of parent psychiatric history. The medium-risk group (35.1%) had difficulties with parent knowledge, financial strain, and risk factors for medication nonadherence. The low-risk group (35.1%) demonstrated no difficulties with adherence or financial strain. Clusters were prospectively associated with transplant status, such that those in the high-risk group were less likely to be transplanted within 1 year post-evaluation.

CONCLUSIONS

The revised P-TRI demonstrated good construct validity as risk level appeared to be associated with transplant listing status 1 year post-evaluation. These results suggest that standardized pretransplant psychosocial risk assessment tools may have value in optimizing transplant access if they can be paired with targeted, multidisciplinary interventions to address concerns early in the transplant process.

Caregiver perspectives of dialysis initiation for children with kidney disease: a qualitative study

BACKGROUND

To better support family-centered care surrounding dialysis initiation, greater understanding of caregiver experience is necessary.

METHODS

Using thematic analysis, we conducted a secondary analysis of semi-structured interview data from a qualitative study of caregivers of children receiving dialysis recruited from 3 pediatric centers. Prominent themes in caregiver experience of caring for a child initiating dialysis were identified.

RESULTS

Thirty-five caregivers participated. Three major themes emerged from qualitative analysis: (1) parenting disrupted - caregivers experienced an acute disruption in their parenting role due to the unexpected, emergent circumstances and vast information accompanying their child's diagnosis; (2) redefining parenting - caregivers sought to reestablish their innate parental role and foster their evolving medical provider role through reassurance that their child could survive, communication with the medical team, and engaging in care plan development; and (3) leveraging dual identities - to positively impact their child's experience and enable flourishing, caregivers leveraged their established caregiver role and newly realized medical provider role through voicing their perspectives, watching over their child's care, and preparing for future changes in their child's health. If caregivers' evolution was not nurtured and enabled, acute fluctuations in their child's care could contribute to future disruption and need to restore their parental role. However, if caregiver development was fostered, caregivers acquired increased ability to prepare for vacillations in their child's care.

CONCLUSIONS

Improving delivery of family-centered care and support of caregivers at dialysis initiation will require directed efforts by nephrology care teams to foster caregiver evolution and resilience and respond to the family's changing experience of kidney disease. A higher resolution version of the Graphical abstract is available as Supplementary information.

Experiences and Needs of Families Caring for Children and Adolescents With Chronic Kidney Disease: A meta-Synthesis

PROBLEM

Families struggle to care for children and adolescents with chronic kidney disease (CKD). They face extensive burden of care and altered family dynamics.

ELIGIBILITY CRITERIA

A meta-synthesis review was conducted to explore the experiences and needs of families caring for children and adolescents with CKD using seven electronic databases (CINAHL, EMBASE, ProQuest Dissertations and Theses, PsycINFO, PubMed, Scopus, and Web of Science). The inclusion criteria are (1) qualitative English studies from January 2010 to December 2020 that (2) report personal experiences or needs of (3) family members caring for children and adolescents aged 19 years and below who have been diagnosed with CKD of any stage (4) across all settings. Quality appraisal was done using the Critical Appraisal Skill Program checklist. Data was synthesised using Sandelowski & Barroso's (2007) method.

SAMPLE

2,236 records were identified and 13 eligible studies were included. Family members involved mothers (n = 190), fathers (n = 83), siblings (n = 5), and grandparents (n = 2).

RESULTS

Three themes emerged: (1) demands of caregiving, (2) support systems, and (3) defining and making sense of new reality.

CONCLUSIONS

Family caregivers experience overwhelming demands of caregiving and unmet support needs to cope. Appropriate interventions are needed to alleviate their burden.

IMPLICATIONS

Knowledge of learning and support needs of families caring for children with CKD may shape nursing education and practice to cultivate more effective communication for better psychosocial family support.

Pediatric peritoneal dialysis in Brazil: a discussion about sustainability. A document by the Brazilian Society of Nephrology, the Brazilian Society of Pediatrics, the Brazilian Association of Organ Transplantation, and the Brazilian Association of Dialysis and Transplant Centers

INTRODUçÃO

A diálise peritoneal (DP) é importante para a pediatria. Este estudo mostrou dados de centros brasileiros que utilizam DP pediátrica.

MÉTODO

Estudo transversal, observacional, descritivo com questionário eletrônico. Incluiu-se pacientes de 0-18 anos em DP cadastrados nos bancos de dados dos diversos centros. Questionário preenchido anonimamente, sem dados de identificação. Foi adotada metodologia quantitativa.

RESULTADOS

212 pacientes estão em DP no Brasil (agosto, 2021). 80% têm menos de 12 anos de idade. A maioria realiza DP automatizada e 74% são dependentes do Sistema Único de Saúde. Em 25% dos centros faltou material de DP e em 51% os pacientes pediátricos foram convertidos de DP para HD.

CONCLUSÃO

A maioria dos pacientes tinha menos de 12 anos e era dependente do SUS. A escassez de insumos aconteceu em 25% dos centros. Esses dados apontam para o problema da sustentabilidade de DP, única alternativa de TRS em crianças muito pequenas.

Sleep disturbance and psychological distress among hospitalized children in India: Parental perceptions on pediatric inpatient experiences

PURPOSE

Investigate parental perceptions of children's sleep disturbance and psychological distress associated with an inpatient stay in a low-resource hospital setting.

DESIGN AND METHODS

Demographic and validated survey instruments were adapted for administration to parents of children in the medical wards of a tertiary hospital in India. Parents proficient in English, Hindi, Tamil, or Telugu with a child age 4-12 years admitted for at least 48 h were eligible to participate. All respondents completed the Factors Affecting Sleep Disturbance Scale, Sleep Duration Questionnaire, Sleep Disturbance Scale, and Kessler Psychological Distress Scale. Data analysis entailed descriptive statistics, correlations, and multivariate regressions to analyze relationships across responses on demographics, sleep disturbance, and psychological distress.

RESULTS

Among 105 parents with hospitalized children, most had children 4-6 years old (54%), including 65% boys and 35% girls. Parents reported that their children slept overnight in the hospital for a mean of 8.3 ± 1.6 h. Children 4-6 year old (relative risk ratio [RRR] = 0.63, p = .004), dyspnea (RRR = 8.73, p = .04), previous hospitalization (RRR = 9.17, p = .03), nighttime procedures (RRR = 2.97, p = .03, and missing home (RRR = 6.78, p < .001) were the factors affecting sleep. Factors affecting psychological distress was nighttime medication administration (RRR = 4.92, p = .01). Sleep disturbances correlated with psychological distress (r = 0.56; p < .01).

CONCLUSION

Sleep disturbance and associated psychological distress in hospitalized children were widely reported by parents queried in this low-resource hospital setting.

PRACTICAL IMPLICATIONS

Nurses can lead efforts in ameliorating sleep in hospitalized children, including partnering with stakeholders on measures to reduce sleep disruption. Child-centered interventions may improve sleep hygiene and decrease psychological distress among children.

Caregiver burden in pediatric dialysis: application of the Paediatric Renal Caregiver Burden Scale

BACKGROUND

Caring for a child with kidney failure on dialysis profoundly impacts caregivers' lives, yet the depth of this burden is not well understood. The Paediatric Renal Caregiver Burden Scale (PR-CBS) is a recently validated instrument used to measure caregiver burden in this population.

METHODS

We performed a cross-sectional study of caregiver burden for caregivers of children with kidney failure receiving dialysis at three pediatric centers. Caregivers completed the PR-CBS instrument as part of a larger qualitative study of caregiver experience. We performed descriptive statistics. T-tests were used to examine differences between dialysis modality and within key demographics. Multivariate linear regression was utilized to assess associations between significant factors and total score.

RESULTS

Ten caregivers of children receiving peritoneal dialysis (PD) and 21 receiving hemodialysis (HD) participated. Total burden score and mean score for every domain was higher for caregivers of children on HD compared to PD. PR-CBS score was significantly associated with younger child age and married status in caregivers. In adjusted multivariate analysis, dialysis modality and married marital status were significantly associated with PR-CBS score.

CONCLUSIONS

This study found that dialysis caregivers experience significant caregiver burden and demonstrates the utility of the PR-CBS in an American population. We found higher burdens among HD caregivers, younger children, and married caregivers. While these findings must be replicated on a larger scale, they suggest possible areas for targeted interventions to improve the quality of life of children with kidney failure and their families. A higher resolution version of the Graphical abstract is available as Supplementary information.

The perspectives of health professionals and patients on racism in healthcare: A qualitative systematic review

OBJECTIVE

To understand racial bias in clinical settings from the perspectives of minority patients and healthcare providers to inspire changes in the way healthcare providers interact with their patients.

METHODS

Articles on racial bias were searched on Medline, CINAHL, PsycINFO, Web of Science. Full text review and quality appraisal was conducted, before data was synthesized and analytically themed using the Thomas and Harden methodology.

RESULTS

23 articles were included, involving 1,006 participants. From minority patients' perspectives, two themes were generated: 1) alienation of minorities due to racial supremacism and lack of empathy, resulting in inadequate medical treatment; 2) labelling of minority patients who were stereotyped as belonging to a lower socio-economic class and having negative behaviors. From providers' perspectives, one theme recurred: the perpetuation of racial fault lines by providers. However, some patients and providers denied racism in the healthcare setting.

CONCLUSION

Implicit racial bias is pervasive and manifests in patient-provider interactions, exacerbating health disparities in minorities. Beyond targeted anti-racism measures in healthcare settings, wider national measures to reduce housing, education and income inequality may mitigate racism in healthcare and improve minority patient care.

Adding Life to Their Years: The Current State of Pediatric Palliative Care in CKD

Despite continued advances in medical treatment, pediatric CKD remains an unremitting, burdensome condition characterized by decreased quality of life and earlier death. These burdens underscore the need for integration of pediatric palliative care (PPC) into nephrology practice. PPC is an evolving field that strives to (1) relieve physical, psychologic, social, practical, and existential suffering; (2) improve quality of life; (3) facilitate decision making; and (4) assist with care coordination in children with life-threatening or life-shortening conditions. Integration of palliative care into routine care has already begun for adults with kidney disease and children with other chronic diseases; however, similar integration has not occurred in pediatric nephrology. This review serves to provide a comprehensive definition of PPC, highlight the unmet need in pediatric nephrology and current integration efforts, discuss the state of palliative care in adult nephrology and analogous chronic pediatric disease states, and introduce future opportunities for study.