Symptom Prevalence and the Negative Emotional States in End-Stage Renal Disease Patients with or without Renal Replacement Therapy: A Cross-Sectional Analysis

Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease

BACKGROUND

Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD.

METHODS

Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice.

RESULTS

With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD.

CONCLUSIONS

Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients.

Mindfulness-based intervention as a symptom management strategy in patients with end-stage renal disease: A controlled clinical trial

AIM

The study's purpose was to examine the effect of mindfulness-based intervention (MBI) on physical and psychological symptoms in patients with end-stage renal disease (ESRD) in Jordan.

METHODS

A repeated-measure randomized control study was conducted in a haemodialysis unit in Jordan between April 2023 and July 2023. Participants (N = 61) were selected using convenience sampling and then randomly assigned into experimental and control groups. The experimental group performed 30-min MBI, three times a week for 8 weeks during haemodialysis sessions. The Depression, Anxiety and Stress Scale-21 and the Patient Health Questionnaire-15 were used to measure the outcomes at baseline, after 5 weeks of the intervention and at the end of the intervention.

RESULTS

Mixed-model repeated-measure ANOVAs revealed that the experimental group showed significantly lower levels of stress, depression and physical symptoms than the control group over time. Within-subject repeated-measure ANOVAs revealed that, in the experimental group, physical symptoms improve significantly over the three points of time. However, significant reductions in psychological symptoms occurred 5 weeks after initiating the intervention, but there was no further significant improvement at the end of the intervention.

CONCLUSION

The study supports the integration of MBI as a symptom management strategy into nursing care plans of patients with ESRD.

TRIAL REGISTRATION

Clinical trial.gov; registration ID: NCT06064708.

Effect of Cognitive Behavioral Intervention Combined with the Resilience Model to Decrease Depression and Anxiety Symptoms and Increase the Quality of Life in ESRD Patients Treated with Hemodialysis

The aim of this study was to compare the effect of cognitive behavioral intervention (CBI) combined with the resilience model (CBI + R) vs CBI alone on depression symptoms, anxiety symptoms, and quality of life of end-stage renal disease (ESRD) patients undergoing hemodialysis replacement therapy.

METHOD

Fifty-three subjects were randomly assigned to one of two treatment groups. The control group (n = 25) was provided with treatment strategies based on a cognitive behavioral approach, while the experimental group (n = 28) were given the same techniques plus resilience model strategies. Five psychological instruments were applied: Beck Depression Inventory, Beck Anxiety Inventory, Mexican Resilience Scale, cognitive distortions scale, and the Kidney Disease related Quality of Life questionnaire. Participants were assessed at baseline (before treatment), eight weeks later (end of treatment), and four weeks after the end of treatment (follow up). The results were analyzed by ANOVA for repeated measures with a Bonferroni-adjusted test method, with p < 0.05 considered significant.

RESULTS

The experimental group had significant differences in total and somatic depression as well as differences in the dimensions of cognitive distortions and a significant increase in the dimensions of resilience. The control group had significant differences in all variables but showed lower scores in the evaluated times.

CONCLUSIONS

The resilience model strengthens and enhances the effectiveness of the cognitive behavioral approach to reduce symptoms of depression and anxiety in patients with ESRD.

Prevalence and Severity of Lower Gastrointestinal Symptoms amongst Non-Dialysis Chronic Kidney Disease Patients: A Systematic Review and Meta-Analysis

Chronic kidney disease (CKD) patients experience a wide range of symptoms that deteriorate their health-related quality of life (HRQoL). We aimed to estimate the prevalence and severity of lower gastrointestinal (GI) symptoms in non-dialysis CKD adult outpatients, and to summarize the relationships between these symptoms and HRQoL, laboratory test results, and clinical data. The protocol of the study was preregistered (PROSPERO CRD42021255122). We searched MEDLINE, Scopus, Web of Science, and grey literature sources from the databases' inception up until 27 November 2021. Wide citation chasing was conducted. Single proportions (prevalence of functional constipation, self-reported constipation, diarrhea, abdominal bloating, fecal incontinence, and abdominal/rectal pain) were pooled using generalized linear mixed models. A total of 37 studies with 12,074 patients were included. We found that lower GI symptoms, especially self-reported abdominal bloating [CKD G1-2: 48.45% (95% CI: 43.5-53.4%; 2 studies); G3: 46.95% (95% CI: 45.0-48.9%; 2 studies), G4-5: 36.1% (95% CI: 25.4-48.5%; 8 studies)] and constipation [CKD G1-2: 31.8% (95% CI: 13.9-54.9%); G3: 29.8% (95% CI: 21.2-40.1%; 4 studies); G4-5: 38.8% (95% CI: 30.9-47.4%); 22 studies)], were common in non-dialysis CKD patients. The severity of the symptoms was limited. Self-reported constipation was most consistently associated with worse HRQoL, whereas hard stool consistency was associated with higher uremic toxins levels. To conclude, since lower GI symptoms are common in CKD, using symptom questionnaires that do not take them into account cannot provide full insight into the patient's experience. Further studies are needed to cover identified knowledge gaps, including the exploration of the pathophysiology of GI symptoms in CKD with multi-omics data.

Factors Associated with Symptom Burden in Adults with Chronic Kidney Disease Undergoing Hemodialysis: A Prospective Study

People with end stage renal disease and undergoing hemodialysis experience a high symptom burden that impairs quality of life. This study aimed to assess the prevalence, dynamicity and determinants of symptom burden among middle-aged and older adult hemodialysis patients. A descriptive cross-sectional study together with a longitudinal assessment was used. A total of 118 and 102 hemodialysis patients were assessed at baseline and at a 6-month follow-up. Validated questionnaires were used to assess the symptom burden, stress, illness perception and social support. Multiple linear regression analysis was used to determine the factors associated with symptom burden. The median number of symptoms experienced was 21 (Interquartile Range (IQR); 18−23) and 19 (IQR; 13−22) at baseline and 6 months, respectively. Having elevated stress (β = 0.65, p ≤ 0.005) and illness perception (β = 0.21, p = 0.02) were significantly predicted symptom burden at baseline (F (4, 112) = 55.29, p < 0.005, R2 = 0.664). Stress (β = 0.28, p = 0.003), illness perception (β = 0.2, p = 0.03), poor social support (β = −0.22, p = 0.01) and low body weight (β = −0.19, p = 0.03) were the determinants for symptom burden at 6 months (F (5, 93) = 4.85, p ≤ 0.005, R2 = 0.24). Elevated stress, illness perception level, poor social support and low post-dialysis body weight were found to be determinants for symptom burden. Attention should be given to psychosocial factors of hemodialysis patients while conducting assessment and delivering care to patients.

Fatigue in CKD: Epidemiology, Pathophysiology, and Treatment

Fatigue is a commonly reported and debilitating symptom among patients with CKD, yet little is known about its epidemiology, pathogenesis, and treatment. Various measurement tools have been used in published studies to identify and quantify fatigue. These include several single-item measures embedded in longer questionnaires for assessing depression, quality of life, or symptom burden in patients with kidney disease. Approximately 70% of patients with CKD report fatigue, with up to 25% reporting severe symptoms. Patient-reported fatigue is associated with death, dialysis initiation, and hospitalization among individuals with CKD. The pathophysiology is multifactorial and likely includes decreased oxygen delivery and increased reliance on anaerobic metabolism, thus generating lactic acidosis in response to exertion; the effects of chronic metabolic acidosis and hyperphosphatemia on skeletal muscle myocytes; protein-energy wasting and sarcopenia; and depression. Physical activity has been shown to improve fatigue in some small but promising trials, and so should be recommended, given the additional benefits of exercise. Targeting higher hemoglobin levels with erythropoiesis-stimulating agents may improve fatigue, but potential adverse cardiovascular effects preclude their use to solely treat fatigue without the presence of another indication. Current guidelines recommend cautious individualization of hemoglobin targets for those at low cardiovascular risk who still experience fatigue or functional limitation despite a hemoglobin level of 10 g/dl. Sodium bicarbonate supplementation for the treatment of metabolic acidosis may also improve functional status. Selective serotonin reuptake inhibitors have not been consistently shown to improve fatigue in patients with kidney disease, but an ongoing trial will evaluate the effect of alternative antidepressant drug and behavioral activation therapy on fatigue in patients with CKD. Overall, more research is needed to further clarify underlying mechanisms of fatigue and identify effective, targeted treatments for patients with CKD.

Assessment of kidney disease knowledge among chronic kidney disease patients in the Kingdom of Saudi Arabia

BACKGROUND

The persistent global increase in chronic kidney disease (CKD) prevalence highlights the importance of providing patients with sufficient knowledge to allow them to self-manage their disease.

OBJECTIVES

To gain insights into non-dialysis CKD patients' knowledge of their disease, and assess associations between knowledge and sample characteristics.

DESIGN

A descriptive cross-sectional design was undertaken.

PARTICIPANTS

A convenience sample of 203 stages 3-5 CKD patients was recruited.

MEASUREMENTS

The Kidney Disease Knowledge Survey (KiKs) was used.

RESULTS

This study revealed that the mean age of the patients was 47.34 years. 50.2% were male and most (75.9%) were married. The mean score of knowledge (measured using KiKs) relating to kidney disease was 17.87 ± 3.212. The lowest scores were related to knowledge of effects of proteinuria (13.3%), meanings of "glomerular filtration rate" (29.6%) and "targeted blood pressure" (31.5%). Although more than 60% of participants knew about some kidney functions, they misunderstood others, including those related to glucose control (23.6%) and blood pressure (54.7%). Patients displayed knowledge scores >70% for five other areas, including disease stage and time since diagnosis. Almost all participants did not know that chronic kidney disease (CKD) could be asymptomatic. The results showed that late-stage CKD (Stages 4 and 5) and longer time since diagnosis of CKD were independently associated with a higher score of knowledge (r = 0.18, p = 0.017; r = 0.41, p < 0.001; r = 0.26, p = 0.001, respectively).

CONCLUSIONS

This study provided initial insights on CKD-related knowledge among patients with Stage 3-5 CKD in the Kingdom of Saudi Arabia. Many gaps in knowledge were identified, especially those relating to blood pressure. More studies are required to fully understand the extent of the knowledge deficit in the wider population; however, these findings will allow nurses to address significant gaps.

The Prevalence and Severity of Chronic Pain in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Background:

Chronic pain is a common and distressing symptom reported by patients with chronic kidney disease (CKD). Clinical practice and research in this area do not appear to be advancing sufficiently to address the issue of chronic pain management in patients with CKD.

Objectives:

To determine the prevalence and severity of chronic pain in patients with CKD.

Design:

Systematic review and meta-analysis.

Setting:

Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity.

Patients:

Adults with glomerular filtration rate (GFR) category 3 to 5 CKD including dialysis patients and those managed conservatively without dialysis.

Measurements:

Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of pain, and severity of pain.

Methods:

Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library, last searched on February 3, 2020. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of overall chronic pain, musculoskeletal pain, bone/joint pain, muscle pain/soreness, and neuropathic pain and the I² statistic was computed to measure heterogeneity. Random effects models were used to account for variations in study design and sample populations and a double arcsine transformation was used in the model calculations to account for potential overweighting of studies reporting either very high or very low prevalence measurements. Pain severity scores were calibrated to a score out of 10, to compare across studies. Weighted mean severity scores and 95% confidence intervals were reported.

Results:

Sixty-eight studies representing 16 558 patients from 26 countries were included. The mean prevalence of chronic pain in hemodialysis patients was 60.5%, and the mean prevalence of moderate or severe pain was 43.6%. Although limited, pain prevalence data for peritoneal dialysis patients (35.9%), those managed conservatively without dialysis (59.8%), those following withdrawal of dialysis (39.2%), and patients with earlier GFR category of CKD (61.2%) suggest similarly high prevalence rates.

Limitations:

Studies lacked a consistent approach to defining the chronicity and nature of pain. There was also variability in the measures used to determine pain severity, limiting the ability to compare findings across populations. Furthermore, most studies reported mean severity scores for the entire cohort, rather than reporting the prevalence (numerator and denominator) for each of the pain severity categories (mild, moderate, and severe). Mean severity scores for a population do not allow for “responder analyses” nor allow for an understanding of clinically relevant pain.

Conclusions:

Chronic pain is common and often severe across diverse CKD populations providing a strong imperative to establish chronic pain management as a clinical and research priority. Future research needs to move toward a better understanding of the determinants of chronic pain and to evaluating the effectiveness of pain management strategies with particular attention to the patient outcomes such as overall symptom burden, physical function, and quality of life. The current variability in the outcome measures used to assess pain limits the ability to pool data or make comparisons among studies, which will hinder future evaluations of the efficacy and effectiveness of treatments. Recommendations for measuring and reporting pain in future CKD studies are provided.

Trial registration:

PROSPERO Registration number CRD42020166965

Association of motivations and barriers with participation and performance in a pedometer-based intervention

BACKGROUND

A randomized trial of a pedometer-based intervention with weekly activity goals led to increased walking among dialysis patients. However, the association of participant-expressed motivations and barriers to participation and performance in such an intervention has not been determined.

METHODS

Thirty dialysis patients were randomized to a 12-week pedometer-based intervention with weekly step goals. Participants were asked about motivations and barriers to the increasing activity via weekly semi-scripted telephone interviews. We examined the association of these motivations and barriers with achieving weekly goals, reaching overall targets and increasing steps through multivariable linear and logistic regression analyses adjusted for age, sex, body mass index, dialysis modality and baseline steps.

RESULTS

The most common motivations were desire to maintain/improve functional ability (30%) and activity (30%). The most common barriers were health-related (33%). Motivation to maintain/improve functional ability was associated with achieving weekly goals 17.9% more often [95% confidence interval (CI) 1.7-34.2] and with a greater increase in steps (1524 steps; 95% CI 61-2989) than those lacking this motivation. Experiencing a health-related barrier was not associated with the decreased achievement of weekly goals but was associated with lower odds of reaching overall targets (odds ratio = 0.06; 95% CI 0.01-0.53) and a smaller increase in steps (-1640 steps, 95% CI -3244 to -36). No patients who reported weather/environmental barriers or safety concerns reached overall targets.

CONCLUSIONS

Participants who express a desire to maintain/improve functional ability may be particularly suited for activity interventions. Health-related setbacks should be met with revised goals. Reporting environmental or safety concerns may merit lowering overall targets.

Oral health-related quality of life in adult patients with end-stage kidney diseases undergoing renal replacement therapy - a systematic review

Background

The oral health of patients undergoing renal replacement therapy (RRT) is insufficient. Poor oral health and its components can affect the oral health-related quality of life (OHRQoL) of these patients. The aim of this systematic review was to assess the OHRQoL of adult patients under RRT.

Methods

A systematic literature search was performed using the terms: dialysis OR “renal disease” OR kidney OR “renal failure” OR “kidney transplantation” OR hemodialysis OR “peritoneal dialysis” OR “renal replacement therapy” AND “oral health-related quality of life”, complemented by manual search. Clinical studies including adults (age ≥ 18 years) that were published between 2009 and 2019 were included in qualitative analysis.

Results

Twelve out of 20 studies were included in the qualitative analysis. The majority (11/12 studies) included patients undergoing haemodialysis (HD), with a sample size between 47 and 512 participants. Two studies included patients after kidney transplantation. Only one-quarter of the investigations included a healthy control group. The overall OHRQoL was found to be reduced. The majority of studies found relationships between OHRQoL and different oral health parameters. Furthermore, several relationships between OHRQoL and general quality of life as well as disease related parameters including age, gender, diabetes, blood parameters and dialysis duration were found. OHRQoL subscales psychological/psychosocial impairment and pain were predominantly affected.

Conclusions

Patients under RRT suffer from a reduced OHRQoL, which is potentially influenced by oral health and disease related parameters. Interdisciplinary dental care is needed and should consider both physical and psychosocial issues.

Complex arts-based interventions for patients receiving haemodialysis: A realist review

Many patients with end-stage kidney disease require haemodialysis, a treatment that requires attending hospital three times a week for four hours each visit. This treatment impacts profoundly on mental health. Arts-based interventions for patients receiving haemodialysis could address the impact of this treatment; however, there is no consensus on methods of implementation and mechanisms underlying these interventions in specific clinical contexts. Using a realist approach, relevant articles were synthesised to inform theory relating to the mechanism and implementation of complex arts-based interventions for haemodialysis patients. The theoretical framework includes two implementation phases, firstly delivery of person-centred art activities during haemodialysis and secondly, display of completed artwork. This intervention triggers mechanisms including flow and social capital. Implementation is hindered by constraints of the haemodialysis unit and patients' lack of confidence in their artistic skills. These issues can be addressed through aflexible approach to implementation and support from healthcare professionals.

A Walking Intervention to Increase Weekly Steps in Dialysis Patients: A Pilot Randomized Controlled Trial

RATIONALE & OBJECTIVE

Patients receiving dialysis report very low physical activity. We implemented a pilot trial to assess the feasibility of a pedometer-based intervention to gather preliminary evidence about its impact on physical activity, symptoms, and surrogates of cardiovascular risk.

STUDY DESIGN

Pilot randomized controlled trial.

SETTING & PARTICIPANTS

60 dialysis patients from San Francisco dialysis clinics.

INTERVENTION

Participants were randomly assigned 1:1 to receiving pedometers with weekly step goals or usual care for 3 months.

OUTCOMES

The primary outcome was step counts, measured using pedometers. Secondary outcomes included physical performance using the Short Physical Performance Battery, the Physical Function and Vitality scales of the 36-Item Short Form Health Survey, the Dialysis Symptoms Index, and the Center for Epidemiologic Studies-Depression Scale, with endothelial function as a secondary and heart rate variability as an exploratory surrogate measure of cardiovascular risk. Targeted enrollment was 50% and targeted completion was 85%.

RESULTS

49% of approached patients were enrolled, and 92% completed the study. After 3 months, patients randomly assigned to the intervention (n=30) increased their average daily steps by 2,256 (95% CI, 978-3,537) more than the 30 controls (P<0.001). Heart rate variability (standard deviation of N-N intervals) increased by 14.94 (95% CI, 0.31-33.56) millisecondsin the intervention group as compared with controls (P = 0.05). There were no statistically significant differences across intervention groups in symptoms, physical performance, or endothelial function. Participants in the intervention group reverted to baseline steps during the postintervention follow-up.

LIMITATIONS

The Northern California study setting may limit generalizability. Walking does not capture the full spectrum of physical activity.

CONCLUSIONS

A short-term pedometer-based intervention led to increased step counts in dialysis patients, but the increase was not sustained. Pedometer-based interventions are feasible for dialysis patients, but future studies are needed to address whether more prolonged interventions can improve physical function or symptoms.

FUNDING

Supported by grants from the American Kidney Fund, National Institutes of Health-National Institute of Diabetes and Digestive and Kidney Diseases, and International Society of Nephrology.

TRIAL REGISTRATION

Registered at ClinicalTrials.gov with study identifier NCT02623348.

Depression and anxiety among patients undergoing dialysis and kidney transplantation: a cross-sectional study

BACKGROUND

Depression and anxiety are the most prevalent psychological disorders among end-stage renal disease patients and are associated with various conditions that result in poorer health outcomes, e.g. reduced quality of life and survival. We aimed to investigate the prevalences of depression and anxiety among patients undergoing renal replacement therapy.

DESIGN AND SETTING

Cross-sectional study in Belo Horizonte, Brazil.

METHODS

Patients' depression and anxiety levels were assessed using the Beck Inventory. The independent variables were the 36-Item Short-Form Health Survey (SF-36), Charlson Comorbidity Index and Global Subjective Assessment, along with sociodemographic and clinical characteristics.

RESULTS

205 patients were included. Depression and anxiety symptoms were detected in 41.7% and 32.3% of dialysis patients and 13.3% and 20.3% of transplantation patients, respectively. Lower SF-36 mental summary scores were associated with depression among transplantation patients (odds ratio, OR: 0.923; 95% confidence interval, CI: 0.85-0.99; P = 0.03) and dialysis patients (OR: 0.882; 95% CI: 0.83-0.93; P ≤ 0.001). Physical component summary was associated with depression among dialysis patients (OR: 0.906; 95% CI: 0.85-0.96; P = 0.001). Loss of vascular access (OR: 3.672; 95% CI: 1.05-12.78; P = 0.04), comorbidities (OR: 1.578; 95% CI: 1.09-2.27; P = 0.01) and poorer SF-36 mental (OR: 0.928; 95% CI: 0.88-0.97; P = 0.002) and physical (OR: 0.943; 95% CI: 0.89-0.99; P = 0.03) summary scores were associated with anxiety among -dialysis patients.

CONCLUSIONS

Depression and anxiety symptoms occurred more frequently among patients undergoing dialysis. Quality of life, comorbidities and loss of vascular access were associated factors.

Fatigue in Nondialysis Chronic Kidney Disease: Correlates and Association with Kidney Outcomes

BACKGROUND

Fatigue, although common and associated with outcomes in dialysis-dependent chronic kidney disease (CKD), has not been studied in nondialysis chronic kidney disease (CKD-ND) patients.

METHODS

In this longitudinal cohort of 266 outpatients with CKD-ND stages 2-5, we measured self-reported fatigue on 3 scales-Quick Inventory of Depression Symptomatology-Self Report (QIDS-SR16), Beck Depression Inventory-I (BDI-I), and short form 12 health survey (SF-12) questionnaires and evaluated the prespecified composite of progression to dialysis initiation, death, or hospitalization after 12 months. Logistic and linear regression assessed characteristics associated with fatigue. Survival analysis measured associations of fatigue with outcomes.

RESULTS

Mean age was 64.4 ± 12.0 years, and mean estimated glomerular filtration rate (eGFR) was 31.6 ± 16.7 mL/min/1.73 m2. Fatigue was common, with 69.2% reporting fatigue on QIDS-SR16 and 77.7% on BDI-I. Unemployment, comorbidities, use of antidepressant medications, and lower hemoglobin correlated with fatigue. There were 126 outcome events. Participants that reported any versus no fatigue on QIDS-SR16 were more likely to reach the composite, hazard ratio (HR) 1.70 (95% CI 1.11-2.59), which persisted after adjusting for demographics, comorbidities, substance abuse, hemoglobin, albumin, eGFR, and calcium-phosphorus product, HR 1.63 (1.05-2.55). Fatigue severity by the SF-12 was also associated with outcomes independent of demographics, comorbidities, and substance abuse, HR per unit increase 1.18 (1.03-1.35). No association was observed with fatigue on the BDI-I.

CONCLUSION

Fatigue affected about 2/3 of CKD-ND patients and associated with unemployment, comorbidities, antidepressant medication use, and anemia. Fatigue measured by the QIDS-SR16 and SF-12 independently predicted outcomes in CKD patients. Eliciting the presence of fatigue may be a clinically significant prognostic assessment in CKD patients.

Quality of life, symptoms, and sleep quality of elderly with end-stage renal disease receiving conservative management: a systematic review

BACKGROUND

Older patients with end-stage renal disease (ESRD) have experienced diminished quality of life and debilitating symptoms. Conservative management may be a potential treatment option. Currently, limited studies have been conducted about the main outcome of conservative management, including quality of life, symptoms and sleep quality. The aim of this systematic review was to examine the quality of life, symptoms and sleep quality of elderly patients with ESRD undergoing conservative management.

METHODS

Evidence-based medicine database (JBI and Cochrane) and original literature database (PubMed, Medline, EMbase, Web of Science) were searched up to March 12, 2018. The quality of included papers was evaluated with the Newcastle-Ottawa Scale.

RESULTS

Eight studies met the inclusion criteria. The total of 1229 patients were involved with an average age of 60.6 ~ 82 years. Patients choosing conservative management were older and more functionally impaired compared to those opting for dialysis. 55% patients undergoing conservative management had stable or improved quality of life and symptoms in prospective cohort study. However, the results revealed that there were no significant differences in quality of life and symptom between conservative management and renal replacement therapy. Only one study assessed quality of life of older patients using SF-36, with a lower score in physical health subscale of conservative management patients than those of renal replacement therapy. Although more than 40% of the patients had poor sleep quality, no significant difference was found between conservative management and renal replacement therapy. Sleep disorders were associated with fatigue and other symptoms.

CONCLUSIONS

Although there is a limited literature, conservative management is likely to improve quality of life and alleviate symptoms of end-stage renal disease patients with considerable clinical implications mainly in elderly patients. Future study should pay more attention to the various treatment outcomes of conservative management, providing abundant evidence.

Implementing an arts-based intervention for patients with end-stage kidney disease whilst receiving haemodialysis: a feasibility study protocol

BACKGROUND

End-stage kidney disease is a life-changing illness. Many patients require haemodialysis, a treatment that impacts profoundly on quality of life and mental health. Arts-based interventions have been used in other healthcare settings to improve mental health and quality of life; therefore, they may help address the impact of haemodialysis by improving these outcomes. However, there is a lack of evidence assessing their effectiveness in this population and few randomised controlled trials (RCTs) evaluating the effectiveness of complex arts-based interventions.

METHODS

The aims of this study are to establish the feasibility of a cluster RCT of an arts-based intervention for patients with end-stage kidney disease whilst receiving haemodialysis through a cluster randomised pilot study, explore the acceptability of the intervention with a process evaluation and explore the feasibility of an economic evaluation. The study will have three phases. The first phase consists of a cluster randomised pilot study to establish recruitment, participation and retention rates. This will involve the recruitment of 30 participants who will be randomly allocated through cluster randomisation according to shift pattern to experimental and control group. The second phase will be a qualitative process evaluation to establish the acceptability of the intervention within a clinical setting. This will involve semi-structured interviews with 13 patients and three focus groups with healthcare professionals. The third phase will be a feasibility economic evaluation to establish the best methods for data collection within a future cluster RCT.

DISCUSSION

Arts-based interventions have been shown to improve quality of life in healthcare settings, but there is a lack of evidence evaluating arts-based interventions for patients receiving haemodialysis. This study aims to assess the feasibility of a future cluster RCT assessing the impact of an arts-based intervention on the wellbeing and mental health of patients receiving haemodialysis and identify the key factors leading to successful implementation. The hope is this study will inform a trial that can influence future healthcare policy by providing robust evidence for arts-based interventions within the haemodialysis setting.

TRIAL REGISTRATION

The trial was prospectively registered on clinicaltrials.gov on 14/8/2018, registration number NCT03629496.

Higher Physical Activity Is Associated With Less Fatigue and Insomnia Among Patients on Hemodialysis

Introduction

Patients on hemodialysis experience a heavy burden of symptoms that may be related to the low levels of physical activity reported in this population. We hypothesized that physical activity would be inversely related to symptom severity and that depression might mediate this association.

Methods

We designed a cross-sectional study of 48 patients receiving hemodialysis at 3 San Francisco dialysis clinics. Physical activity was measured using pedometers and recorded within 1 week of symptom assessment. Symptoms were assessed using total symptom burden and severity on the Dialysis Symptom Index (DSI; burden 0–29, severity 0–145), individual symptoms on the DSI (0–5), Kidney Disease Quality of Life Vitality scores, (0–100), and the Center for Epidemiologic Study-Depression (0–60).

Results

Median daily step count was 2631 (25th, 75th percentile 1125, 5278). Seventy-three percent of patients reported fatigue. After adjustment for age, sex, diabetes, and serum albumin, physical activity was associated with 0.2 points lower fatigue severity per 1000 steps per day (95% confidence interval [CI] −0.3 to 0.0), P = 0.04. Physical activity was also associated with higher Vitality score (2.36 points per 1000 steps; 95% CI 0.07–4.65) and lower insomnia scores (−0.1 points per 1000 steps; 95% CI −0.3 to 0.0], P < 0.05) in our adjusted models. Physical activity was not associated with other symptoms.

Conclusion

Because the study was cross-sectional, we cannot determine whether physical activity lowers fatigue and insomnia or whether less insomnia and fatigue increase physical activity. However, interventions to increase physical activity should be considered alongside current strategies as a possible approach to managing fatigue and insomnia.