Symptoms among patients receiving in-center hemodialysis: A qualitative study

The effect of video training on symptom burden, comfort level, and quality of life in hemodialysis patients: Clustered randomized controlled trial

OBJECTIVE

Use of video in patient education is becoming widespread due to its low cost, time management, ease of application, and permanent learning. The study aimed to investigate the effect of video training on the symptom burden, comfort level, and quality of life of patients undergoing hemodialysis treatment.

METHODS

In this clustered randomized controlled trial, the patients were randomly assigned to groups by lottery method according to hemodialysis treatment days and sessions. Individuals in the intervention group(n = 26) were screened one episode of the training video in each session for three episodes per week for 12 weeks. Individuals in the control group(n = 22) received only conventional hemodialysis without video training.

RESULTS

At the third and fourth measurement times, in intervention group, mean scores of symptom burden decreased compared to baseline (respectively:40,12 ± 21,63; 22,31 ± 14,08;21,54 ± 16,78), mean scores of comfort level increased (respectively:102,42 ± 13,45; 111,42 ± 8,00;115,04 ± 9,73)(p < 0.05), while there was no significant difference in control group(p > 0.05). This study observed a statistically significant difference between quality of life scale scores individuals in intervention group(p < 0,05).

CONCLUSION

It was concluded that video training delivered to patients undergoing hemodialysis treatment decreased symptom burden of patients and increased their comfort level, and quality of life.

PRACTICE IMPLICATIONS

Video training can be utilized in the educational program of hemodialysis patients.

Pharmacological Treatment for Dialysis-Related Muscle Cramps: A Systematic Review

BACKGROUND

Patients with end-stage renal disease undergoing dialysis suffer from muscle cramps, a prevalent and burdensome symptom for which there is a paucity of efficient and safe treatments.

AIM

What is the efficacy and safety of pharmacological interventions for the treatment of dialysis-related muscle cramps?

DESIGN

A systematic review was conducted in OVID, CINAHL, PubMed, Web of Science, and Central Cochrane databases up to August 25, 2023.

DATA SOURCES

Experimental studies reporting on a pharmacological intervention for the treatment of dialysis-related muscle cramps were included. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis, and the studies quality was assessed with the RoB2 tool.

RESULTS

A total of 4660 studies were retrieved, and 13 articles were included. The studies reported on nine interventions: vitamin C, vitamin E, vitamin K2, vitamin B7, dextrose solutions, gabapentin, sodium chloride, creatine monohydrate, and L-carnitine. The studies testing L-carnitine and creatine monohydrate were the only ones deemed to have a low risk of bias. Side effects were reported in only two trials, consisting primarily of gastrointestinal discomfort and hyperglycemia. Vitamins C and E are the two most studied interventions that showed positive results in reducing the frequency, severity, and duration of dialysis-related muscle cramps. L-carnitine is a promising intervention that warrants further investigation.

CONCLUSION

Our review consolidates the existing evidence, elucidating the range of treatments along with their potential benefits and limitations. Future studies should uphold high-quality standards, incorporate patient-reported outcomes, and utilize well-defined, robust samples to improve patient care.

The Feasibility and Effects of Self-Acupressure on Symptom Burden and Quality of Life in Hemodialysis Patients: A Pilot RCT

Background

Symptom burden among long-term hemodialysis (HD) patients is high, and addressing symptoms has been identified as a key research priority by patients. Acupressure has shown some effectiveness in management of symptoms in patients with HD.

Objective

The purpose of this study was to explore the feasibility and the effect of implementing a self-administered acupressure intervention on symptom burden and quality of life for in-center HD patients.

Design

A pilot randomized controlled study.

Setting

Two outpatient community HD clinics between in Calgary, Alberta, Canada.

Patients or Sample or Participants

Patients on HD for at least 3 months and with at least one symptom score rated greater than moderate were eligible for the study.

Methods

Participants were randomized into either the (1) self-acupressure + usual care or (2) usual care alone group. Participants in the acupressure group were given a wooden acupressure tool and taught how to self-administer protocol on 6 acupressure sites for the 4-weeek study duration. Feasibility outcomes were assessed through satisfaction surveys and attrition. Other outcomes included quality of life and symptom scores by validated questionnaires (EQ-5D-5L and Integrated Palliative Outcome Score-Renal [IPOS-Renal]).

Results

Thirty-two participants were successfully enrolled in the study; acceptability was high with study completion at 98% in the intervention group and 82% adherence rate to the 4-week protocol. Participants in the intervention group reported an improved change score in quality of life (EQ-5D-5L Index Score change = +0.053; EQ-5D-5L visual analog scale score change = +6.7). Participants in the intervention group also reported improved symptom scores (IPOS-Renal overall change = -2.8).

Limitations

Small sample size and intervention duration are limitations of this pilot study.

Conclusions

The results from this study suggest that self-acupressure was acceptable and feasible in this sample of HD patients. Self-acupressure may have a role for supporting the management of symptoms in HD patients. These pilot results can be used to inform larger more definitive investigations.

The effect of education given to hemodialysis patients based on the Roy Adaptation Model on fluid management, symptom control, and quality of life

This study aimed to determine the effect of fluid management, symptom control, and quality of life on education based on the Roy Adaptation Model. This randomized controlled study was conducted with the participation of 107 patients (53 intervention, 54 control). Data were collected using the "Patient Data Collection Form," "Fluid Control in Hemodialysis Patients Scale," "Dialysis Symptom Index," and "Nottingham Health Profile." The forms were filled out through face-to-face interviews with the patients in the intervention and control groups at the 0th (onset), 1st, and 3rd months. The patients in the intervention group were trained with an education booklet based on the Roy Adaptation Model. The results revealed that the education given according to the Roy Adaptation Model improved the compliance with fluid control, quality of life, and symptom control of hemodialysis patients. It is recommended that education based on the Roy Adaptation Model be systematically used by hemodialysis nurses. The results are limited to the population included in the study, and further research on hemodialysis populations is needed.

Symptom perception and self-care practice for uraemic pruritus in patients receiving haemodialysis

BACKGROUND

Due to the recurrent nature of uraemic pruritus among patients receiving haemodialysis, self-care can offer patients a means to ameliorate this symptom. Qualitative data on self-care of uraemic pruritus are limited.

OBJECTIVE

To explore how patients on haemodialysis perceive uraemic pruritus, implement self-care practice, and appraise the outcome of self-caring uraemic pruritus.

DESIGN

The Common Sense Model of Self-Regulation guided the study design.

PARTICIPANTS AND APPROACHES

Data were collected through face-to-face interviews with 30 patients receiving haemodialysis who were aged from 50 to 89 years and had had uraemic pruritus for more than 6 weeks. Interviews were audio recorded, and verbatim transcriptions of interviews were analysed.

FINDINGS

Our participants generally used life-related analogies to describe uraemic pruritus, which they reviewed as a momentarily controllable symptom with an endless timeline. Most participants reported limited knowledge of the aetiology and multifaceted impacts of uraemic pruritus on their daily life and emotional status. The impacts on daily life included decreased zest for activities and sleep disturbances. Physical management of uraemic pruritus involved daily substance use and interventions employed during pruritic episodes. Psychological managements involved preferences for indoor activities and a fatalistic outlook. Unsatisfactory outcomes and psychological burdens from self-care practice were reported.

CONCLUSIONS

Life experiences shape symptom presentation and self-care practice in patients on haemodialysis. The modalities for self-caring for uraemic pruritus are diverse but not remarkably effective. Performing self-care tasks places a substantial burden on patients. Individualised educational programs should be developed to improve the outcome of self-care practice.

Quality of life tools among patients on dialysis: A systematic review

Introduction

 The universal increase in obesity and diabetes has increased the chronic kidney disease (CKD) rate. In 2017, almost 800 million individuals suffered from CKD worldwide. Kidney dialysis becomes necessary as the disease progresses. Dialysis negatively impacts CKD patients' quality of life (QoL). It causes several complications that affect patients' physical, social, psychological, and spiritual aspects of life. This systematic review aims to identify condition-specific tools used to assess CKD patients' quality of life on dialysis.

Material and Methods

A systematic literature search was conducted to investigate studies using QoL tools among patients on dialysis from February 2000 to June 2023. The search was conducted in several databases and followed the PRISMA guidelines. The focus was to identify tools that capture intrinsic factors, such as spiritual subdomains, rather than extrinsic factors, such as environmental subdomains.

Results

The review identified five studies and seven dialysis-specific tools for assessing the QoL of CKD patients on dialysis. The physical domain was the most assessed, followed by the psychological and social domains. Fatigue, muscle weakness, sleep disorders, and pain were identified as the most common concerns in the physical domain.

Conclusion

Dialysis negatively impacts all aspects of QoL in CKD patients. This review can guide clinicians in understanding the disease and treatment burden by identifying the most appropriate tools for assessing the QoL of adult CKD patients undergoing dialysis. There is a need for further studies to explore the detrimental effects of CKD treatment and better understand its impact on patients' QoL.

Potent induction of humoral and cellular immunity after bivalent BA.4/5 mRNA vaccination in dialysis patients

Knowledge on immunogenicity of the bivalent Omicron BA.4/5 vaccine in dialysis patients and the effect of a previous infection is limited. Therefore, vaccine-induced humoral and cellular immunity was analyzed in dialysis patients and immunocompetent controls with and without prior infection. In an observational study, 33 dialysis patients and 58 controls matched for age, sex and prior infection status were recruited. Specific IgG, neutralizing antibody activity and cellular immunity towards the spike-antigen from parental SARS-CoV-2 and Omicron-subvariants BA.1, BA.2 and BA.4/5 were analyzed before and 13-18 days after vaccination. The bivalent vaccine led to a significant induction of IgG, neutralizing titers, and specific CD4+ and CD8+ T-cell levels. Neutralizing activity towards the parental strain was higher than towards the Omicron-subvariants, whereas specific T-cell levels towards parental spike and Omicron-subvariants did not differ indicating substantial cross-reactivity. Dialysis patients with prior infection had significantly higher spike-specific CD4+ T-cell levels with lower CTLA-4 expression compared to infection-naive patients. When compared to controls, no differences were observed between infection-naive individuals. Among convalescent individuals, CD4+ T-cell levels were higher in patients and neutralizing antibodies were higher in controls. Vaccination was overall well tolerated in both dialysis patients and controls with significantly less adverse events among patients. In conclusion, our study did not provide any evidence for impaired immunogenicity of the bivalent Omicron BA.4/5 vaccine in dialysis patients. Unlike in controls, previous infection of patients was even associated with higher levels of spike-specific CD4+ T cells, which may reflect prolonged encounter with antigen during infection.

Experiences of Indigenous Patients Receiving Dialysis: Systematic Review of Qualitative Studies

RATIONALE & OBJECTIVE

Indigenous People suffer a high burden of kidney disease. Those receiving maintenance dialysis have worse outcomes compared with similarly treated non-Indigenous patients. We characterized the experiences of Indigenous patients receiving dialysis in British-colonized countries to gain insights into which aspects of kidney care may benefit from improvement.

STUDY DESIGN

A systematic review of published qualitative interview studies.

SETTING & STUDY POPULATIONS

Indigenous Peoples aged 18 years and over, receiving hemodialysis or peritoneal dialysis in British-colonized countries.

SELECTION CRITERIA FOR STUDIES

Search terms for Indigenous Peoples, dialysis, and qualitative research were entered into Medline, Embase, PsycINFO, and CINAHL and searched from inception to January 5, 2023.

DATA EXTRACTION

Characteristics of each study were extracted into Microsoft Excel for quality assessment.

ANALYTICAL APPROACH

Data were analyzed using thematic synthesis.

RESULTS

The analysis included 28 studies involving 471 participants from Australia, New Zealand, Canada, and the United States. We identified four themes: centrality of family and culture (continuing dialysis for family, gaining autonomy through shared involvement, balancing primary responsibility to care for family); marginalization due to structural and social inequities (falling through gaps in primary care intensifying shock, discriminated against and judged by specialists, alienated and fearful of hospitals, overwhelmed by travel, financial and regimental burdens); vulnerability in accessing health care (need for culturally responsive care, lack of language interpreters, without agency in decision-making, comorbidities compounding complexity of self-management); and distress from separation from community (disenfranchisement and sorrow when away for dialysis, inability to perpetuate cultural continuity, seeking a kidney transplant).

LIMITATIONS

We only included articles published in English.

CONCLUSIONS

Indigenous patients receiving dialysis experience inequities in health care that compound existing accessibility issues caused by colonization. Improving the accessibility and cultural responsiveness of dialysis and kidney transplant services in collaboration with Indigenous stakeholders holds promise to enhance the experience of Indigenous patients receiving dialysis.

PLAIN-LANGUAGE SUMMARY

Worldwide Indigenous populations suffer a high incidence of chronic disease leading to lower life expectancy, particularly for kidney disease, an insidious condition requiring long-term dialysis treatment. By listening to Indigenous dialysis patients' stories, we hoped to understand how to improve their experience. We gathered 28 qualitative research studies from four countries reporting Indigenous adults' experiences of dialysis. They described lacking awareness of kidney disease, poor access to health services, systemic racism, inadequate cultural safety, and being dislocated from family, community, and culture. These findings indicate that respectful collaboration with Indigenous Peoples to craft and implement policy changes holds promise to improve prevention, integrate culturally responsive health care practices, and provide better access to local dialysis services and opportunities for kidney transplants.

Do patients dialysing with higher ultrafiltration rates report more intradialytic symptoms and longer postdialysis recovery times?

BACKGROUND

Many hemodialysis (HD) patients report intradialytic symptoms, and take time to recover postdialysis. To improve quality of life, patient groups have highlighted the need to reduce postdialysis fatigue and other peridialytic symptoms. As compartmental shifts of fluid during dialysis have been proposed to cause peridialytic symptoms we investigated whether patients dialysing with higher ultrafiltration rates (UFR) reported more intradialytic symptoms and recovery times.

METHODS

We reviewed the hospital records of HD patients who completed a self-reported intradialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous midweek pre- and postdialysis segmental bioimpedance measurements.

RESULTS

Six hundred and five patients returned the peridialytic symptom questionnaire with pre- and postdialysis bioimpedance measurements. The majority were male (64.8%), mean age 64.2 ± 15.6 years, duration of dialysis treatment 26.8 (10.7-59.2) months, 85% treated by hemodiafiltration and mean dialysate temperature 35.4 ± 0.4°C. We divided patients into terciles according to UFR adjusted for weight, and there was a greater fall in the ratio of extracellular water (ECW) to total body water (TBW) postdialysis in the nonfistula arm from the lower to middle to higher tercile (0.8 (0-1.54) vs. 1.28 (0.52-1.85) vs. 1.54 (0.78-2.52)), trunk (1.5 (0.74-2.27) vs. 1.53 (0.99-2.2) vs. 1.98 (1.18-2.66)), left leg (1.56 (0.49-2.25) vs. 1.77 (1.24-2.43) vs. 2.08 (1.18-2.95)), lower versus higher tercile p < 0.05. However, no differences in intradialytic symptoms or postdialysis recovery times between the UFR terciles were observed.

CONCLUSION

There were no differences in self-reported intradialytic symptoms or postdialysis recovery times with differing UFRs, despite changes in intracompartmental fluid shifts as measured by changes in ECW/TBW.

Physical and psychosocial burden experienced by women on maintenance hemodialysis

BACKGROUND

The global prevalence of chronic kidney disease is growing at an alarming rate, and the number of patients progressing to kidney failure is increasing. A substantial number of patients are undergoing hemodialysis (HD), which improves health and lengthens life. However, it imposes multiple physical and psychological demands on the patients. With the intensity of symptoms being greater among women, a greater focus is needed to obtain empirical evidence regarding the health problems of females receiving HD.

MATERIALS AND METHODS

A descriptive qualitative design was used to explore the health problems of women undergoing maintenance HD. The sampling technique used was maximum variation purposive sampling. The data were collected through in-depth face-to-face interviews with 12 female patients attending the dialysis unit of a tertiary care hospital in northern Kerala, South India, using a semi-structured interview guide. The interview was audiotaped, and the participant content was later converted verbatim into English. The content was imported to NVivo and coded. Thematic analysis was performed using Braun and Clarke's six-step approach.

RESULT

During data analysis, six major themes and 20 subthemes emerged. The themes include (1) physical suffering, (2) mental agony, (3) restricted life, (4) sexual inactivity, (5) breakdown of social life, and (6) financial hardship.

CONCLUSION

Females undergoing maintenance hemodialysis experience significant health-related issues in all major dimensions of health. They are physically vulnerable, psychologically defeated, and socially detached. The study highlights the need for detailed evaluation and consistently supportive and educational care.

Evaluating the Psychometric Properties of Patient-Reported Outcome Measures for Assessing Symptoms in Hemodialysis: A Systematic Review Using COSMIN Guidelines

CONTEXT

Patient-reported outcome measures (PROMs) may have an important role in screening and monitoring for unpleasant symptoms in kidney failure. However, there is still little evidence on the psychometric properties of the measures available to assess physical and psychological symptoms in people on hemodialysis. This gap makes it difficult to decide which measure is the most appropriate for use in clinical practice and research with this population.

OBJECTIVES

This systematic review aimed to critically appraise, compare, and summarize the quality of the measurement properties of PROMs used to assess symptoms in adults on hemodialysis.

METHODS

The protocol for this review was registered in PROSPERO (CRD42023393441). The last database search update was performed on November 25, 2022. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines informed methodological quality assessment, data extraction, analysis, and synthesis.

RESULTS

Twenty-seven primary studies reported the measurement properties of 16 PROMs used to assess physical and psychological symptoms in adults on hemodialysis. Results showed that most measures lacked the necessary psychometric evidence to attest their suitability for this study population, and few underwent rigorous validation procedures. Overall, caveats were found on methodological quality and evidence of content validity and structural validity, and little data was available on responsiveness, measurement error, and cross-cultural validity.

CONCLUSION

The current systematic review provides the basis for identifying PROMs with potential utility for assessing symptoms in hemodialysis care. Several recommendations are presented to help guide future research aimed at improving the rigor of validation and/or translation procedures of existing (and future) measures using COSMIN guidelines.

Sleep Quality and Its Affecting Factors among Hemodialysis Patients: A Multicenter Cross-Sectional Study

(1) Background: Sleep quality is one of the most important clinical outcomes of hemodialysis (HD) patients, as it can affect their physical and mental health. This study aimed to investigate sleep quality and its affecting factors among patients with HD. (2) Methods: A cross-sectional design was used to investigate the quality of sleep among HD patients in two cities in Saudi Arabia. The data were collected during the period from January to December 2022. A convenience sample of 250 HD patients was selected in this study. Data were collected using the Arabic version of the Pittsburgh Sleep Quality Index (PSQI). (3) Results: About two-thirds of participants (63.6%) had normal sleep, while one-third had poor sleep (36.4%). There was a significant relationship between the participants' age and the quality of sleep, where participants who were aged more than 50 had poorer sleep than those who were younger (p < 0.001). Male and married participants significantly had poor sleep more than female and single participants (p = 0.011 and 0.015, respectively). In addition, participants who were retired, had a higher number of dependents, did not adhere to exercise, and had more comorbidities had significantly poorer sleep than other groups (p = 0.002, 0.016, 0.023, and <0.001, respectively). The level of education, financial status, distance from home to dialysis center, and participants' satisfaction at the time of dialysis had no influence on the quality of sleep among HD patients. The multiple linear regression shows that exercise (p = 0.017), the number of comorbidities (p = 0.008), and the duration of dialysis (p < 0.020) were the independent factors affecting the quality of sleep among HD patients. (4) Conclusions: About one-third of HD patients in this study had poor sleep. There were significant differences between patients' age, gender, marital status, and sleep-quality levels. Moreover, participants who retired, had a higher number of dependents, did not adhere to exercise, and had more comorbidities had significantly poorer sleep than other groups. Future studies should develop appropriate interventions to address the problem of poor sleep quality among HD patients.

The Burden of Pruritus Associated With CKD: A Mixed Methods Analysis Among Patients Undergoing Dialysis

Rationale & Objective

Despite its prevalence and distress to patients, chronic kidney disease-associated pruritus (CKD-aP) is poorly characterized, which may contribute to the condition's underdiagnosis and inadequate management. This study aimed to understand the symptom experience of patients with CKD-aP and the extent to which pruritus impacts their lives.

Study Design

Mixed methods study including one-on-one qualitative interviews and completion of the Skindex-10 Questionnaire (measuring itch-related quality of life).

Setting & Participants

A total of 23 patients undergoing hemodialysis and reporting pruritus at 4 dialysis centers in the United States.

Analytical Approach

Interviews followed a semistructured guide that included targeted and follow-up questions to elicit discussion of patients' symptoms of pruritus, including frequency and variability, impact on activities of daily living, and emotional and social functioning. Interviews were digitally audio-recorded. A coding dictionary was developed from transcripts to analyze themes and concepts.

Results

Participants described their itch with various terms, including "numbness," "pain," and "tingling" on their skin. Itch affected multiple areas but especially the back, usually occurred daily, and was often worse at night. For some, itching was a constant experience. Patients relieved their itch through scratching and various off-label treatments; some reported skin damage from excessive scratching and most indicated treatments provided limited relief. Pruritus considerably disrupted physical function, including sleep, daily activities, social functioning and relationships, and emotional and psychological wellbeing. All participants reported being bothered by their itching during the past week on the Skindex-10 Questionnaire.

Limitations

All participants were from the United States, so the findings may not be generalizable to other countries.

Conclusions

Although symptom experience varies considerably, CKD-aP causes severe distress for many patients undergoing hemodialysis and can profoundly impair their quality of life. The results of this study show the impact of itch from patients' perspectives and highlight the need for greater awareness and better management of this condition.

Plain-Language Summary

Patients with chronic kidney disease often experience itching, or pruritus, but its importance to patients is regularly overlooked. This study used one-on-one interviews to investigate patients' experiences of chronic kidney disease-associated pruritus and how it impacts their lives. We found that participants experienced itch on various body areas and used different words to describe their itch (eg, "numbness" and "pain"). Some reported skin damage from excessive scratching, and many used off-label treatments and other interventions (eg, rubbing alcohol and multiple showers daily), which provided limited relief. For many, itching was experienced daily and severely disrupted sleep, daily activities, interactions with others, and mental wellbeing. These findings reveal chronic kidney disease-associated pruritus severely impacts patients and highlights the need for improved management of this condition.

Influence of Early Postoperative Basal Insulin Treatment and Post-Transplant Diabetes Mellitus Risk on Health-Related Quality of Life in Kidney Transplant Recipients-An Analysis of Data From a Randomized Controlled Trial

Health-related quality of life (HRQOL) improves after kidney transplantation (KT) but declines over time. Studies on the effect of early postoperative basal insulin therapy on HRQOL after KT, especially KTRs at high risk of developing post-transplant diabetes mellitus (PTDM) are missing. Data from a randomized controlled trial on 148 non-diabetic KTRs were analyzed. HRQOL using the KDQOL-SF™ was compared in KTRs who either received early postoperative basal insulin therapy or standard-of-care and in KTRs at risk of developing PTDM. Determinants of HRQOL outcomes were investigated using multivariable linear regression analysis. In total, 148 patients completed the KDQOL-SF at baseline. Standard-of-care or early basal insulin therapy after KT did not influence HRQOL. Overall, KT improved the mental (MCS) and physical component summary (PCS) scores at 6-month after KT, which remained stable during further follow-up visits. However, patients at high-risk for PTDM had significantly greater impairment in the PCS score (baseline, 24 months) without differences in MCS scores. In the multivariable regression analysis, allograft function and hemoglobin levels were associated with decreased MCS and PCS scores, respectively. A limitation of the study is the fact that only around 50% of the ITP-NODAT study patients participated in the HRQOL evaluation. Still, our data clearly show that early basal insulin therapy does not affect HRQOL after KT but is negatively influenced by classical clinical factors and PTDM-risk at 24 months after KT. The latter might be influenced by older age.

Application of deep learning to predict the low serum albumin in new hemodialysis patients

BACKGROUND

Serum albumin level is a crucial nutritional indicator for patients on dialysis. Approximately one-third of patients on hemodialysis (HD) have protein malnutrition. Therefore, the serum albumin level of patients on HD is strongly correlated with mortality.

METHODS

In study, the data sets were obtained from the longitudinal electronic health records of the largest HD center in Taiwan from July 2011 to December 2015, included 1,567 new patients on HD who met the inclusion criteria. Multivariate logistic regression was performed to evaluate the association of clinical factors with low serum albumin, and the grasshopper optimization algorithm (GOA) was used for feature selection. The quantile g-computation method was used to calculate the weight ratio of each factor. Machine learning and deep learning (DL) methods were used to predict the low serum albumin. The area under the curve (AUC) and accuracy were calculated to determine the model performance.

RESULTS

Age, gender, hypertension, hemoglobin, iron, ferritin, sodium, potassium, calcium, creatinine, alkaline phosphatase, and triglyceride levels were significantly associated with low serum albumin. The AUC and accuracy of the GOA quantile g-computation weight model combined with the Bi-LSTM method were 98% and 95%, respectively.

CONCLUSION

The GOA method was able to rapidly identify the optimal combination of factors associated with serum albumin in patients on HD, and the quantile g-computation with DL methods could determine the most effective GOA quantile g-computation weight prediction model. The serum albumin status of patients on HD can be predicted by the proposed model and accordingly provide patients with better a prognostic care and treatment.

Effect of Acupressure on Fatigue in Hemodialysis Patients: A Single-Blinded Randomized Controlled Trial

Objectives: The objective of this study was to investigate the effect of acupressure on fatigue severity, sleep quality, and psychological status in patients with end-stage renal disease (ESRD) receiving hemodialysis (HD) treatment. Design: A single-blinded parallel-group randomized controlled trial. Settings/Location: A medical center in central Java, Indonesia. Subjects: One hundred and six patients who had been receiving HD for at least 3 months were enrolled in this study and randomly assigned to two groups. Interventions: The experimental group received acupressure at K1, ST36, and SP6 acupoints. In contrast, the control group received sham acupressure at 1 cun from these three acupoints. Subjects received acupressure thrice per week for 4 weeks, and pressure on each acupoint was applied for 3 min bilaterally. Outcome measures: The primary outcome was fatigue severity, while sleep quality and psychological status (depression/anxiety) were evaluated as secondary outcomes. Outcomes were assessed using the Brief Fatigue Inventory, Pittsburgh Sleep Quality Index, and Hospital Anxiety and Depression Scale. Results: Acupressure induced a significant medium to large effect on improvement in fatigue (b = -1.71, confidence interval [95% CI]: -1.90 to -1.51, ΔR² = 0.744), sleep quality (b = -5.81, 95% CI: -6.80 to -4.81, ΔR² = 0.525), and anxiety (Estimate = -3.213, 95% CI: -4.238 to -2.188, pseudo R² = 0.292)/depression (Estimate = -3.378, 95% CI: -4.432 to -2.325, pseudo R² = 0.268) in experimental group patients compared to controls. No adverse events of acupressure were reported during the study process. Conclusions: Acupressure significantly and independently improved fatigue, depression/anxiety, and sleep quality in ESRD patients receiving HD. Clinical Trial Registration: NCT05571007.

Higher Symptom Frequency and Severity After the Long Interdialytic Interval in Patients on Maintenance Intermittent Hemodialysis

Introduction

Patients on intermittent hemodialysis (HD) have a high symptom burden. Though studies report higher hospitalizations and mortality after the long interdialytic interval, whether symptoms vary based on the interdialytic interval is unclear.

Methods

This is a prospective observational study of patients over the age of 18 who received in-center HD. Patients were surveyed on the presence and severity of 20 different symptoms at the end of 12 HD sessions. Wilcoxon signed-rank test was used for comparison of severity for each symptom by the interval. Multivariable generalized estimating equation with Poisson regression by repeated measure method was used to determine the association of interdialytic interval and symptom frequency while adjusting for potential confounders.

Results

From the 97 patients enrolled, the most common symptoms were fatigue (60.8%), cramping (58.8%), and dry skin (52.6%). There was large variability in the frequency of symptoms, ranging 0% to 8% of treatments. The most severe symptoms were bone pain (mean severity score 2.2±0.9) and diarrhea (mean severity score 2.2±0.7). Eight of the 20 symptoms were significantly more common after the long interdialytic interval including fatigue (22% vs. 15%, P < 0.001) and cramping (21% vs. 16%, P = 0.003). The long interval had a 37% higher incidence rate for symptoms compared to the short interval even after adjustment. Results were similar across genders.

Conclusion

Symptoms are more common after the long interdialytic interval. Clinical assessment and research evaluating patient symptoms need to be cognizant of when patients are surveyed or include the length of interdialytic interval as a confounding variable.

The Symptom Monitoring with Feedback Trial (SWIFT): protocol for a registry-based cluster randomised controlled trial in haemodialysis

BACKGROUND

Kidney failure prevalence is increasing worldwide. Haemodialysis, peritoneal dialysis or kidney transplantation are undertaken to extend life with kidney failure. People receiving haemodialysis commonly experience fatigue, pain, nausea, cramping, itching, sleeping difficulties, anxiety and depression. This symptom burden contributes to poor health-related quality of life (QOL) and is a major reason for treatment withdrawal and death. The Symptom monitoring WIth Feedback Trial (SWIFT) will test the hypothesis that regular symptom monitoring with feedback to people receiving haemodialysis and their treating clinical team can improve QOL.

METHODS

We are conducting an Australia and New Zealand Dialysis and Transplant (ANZDATA) registry-based cluster randomised controlled trial to determine the clinical- and cost-effectiveness at 12 months, of 3-monthly symptom monitoring using the Integrated Palliative Outcome Scale-Renal (IPOS-Renal) survey with clinician feedback, compared with usual care among adults treated with haemodialysis. Participants complete symptom scoring using a tablet, which are provided to participants and to clinicians. The trial aims to recruit 143 satellite haemodialysis centres, (up to 2400 participants). The primary outcome is change in health-related QOL, as measured by EuroQol 5-Dimension, 5-Level (EQ-5D-5L) instrument. Secondary outcomes include overall survival, symptom severity (including haemodialysis-associated fatigue), healthcare utilisation and cost-effectiveness.

DISCUSSION

SWIFT is the first registry-based trial in the Australian haemodialysis population to investigate whether regular symptom monitoring with feedback to participants and clinicians improves QOL. SWIFT is embedded in the ANZDATA Registry facilitating pragmatic recruitment from public and private dialysis clinics, throughout Australia. SWIFT will inform future collection, storage and reporting of patient-reported outcome measures (PROMs) within a clinical quality registry. As the first trial to rigorously estimate the efficacy and cost-effectiveness of routine PROMs collection and reporting in haemodialysis units, SWIFT will provide invaluable information to health services, clinicians and researchers working to improve the lives of those with kidney failure.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12620001061921 . Registered on 16 October 2020.

Effects of music intervention on physical and psychological problems in adults receiving haemodialysis treatment: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To synthesise the effects of music intervention on the physical and psychological problems of adults receiving haemodialysis.

BACKGROUND

Adults receiving haemodialysis experience many physical and psychological problems. Music interventions may have beneficial effect on the management of these problems.

DESIGN

A systematic review and meta-analysis based on PRISMA 2020.

METHODS

This study followed the Cochrane 2021 guideline. Eleven electronic databases were searched from inception to July 2021. Randomised controlled trials that assessed music intervention on haemodialysis-related physical and psychological problems were included. Two authors independently assessed risk of bias with the Cochrane Collaboration tool. The Comprehensive Meta-Analysis software version 3 was used for meta-analysis.

RESULTS

Sixteen randomised controlled trials were included. This meta-analysis demonstrated that music intervention had significant and large effect on physical outcomes such as breath rate, oxygen saturation, arteriovenous fistula puncture-related pain, itching, sleep quality as well as psychological outcomes such as state anxiety and stress. The study also found that music intervention had significant and medium effect on physical outcomes such as systolic and diastolic blood pressure, heart rate and pain, and psychological outcomes such as anxiety. Music intervention had no effect on physical outcomes such as body temperature and cramps, and psychological outcomes such as trait anxiety and depression. Subgroup analyses indicated that sessions of 4-6 are more effective for improving the systolic and diastolic blood pressure and heart rate than three sessions or less. It also found that music duration of 20 min or less is more effective in reducing anxiety compared to music duration of 30 min or more.

CONCLUSIONS

This study demonstrated that music intervention may partially improve haemodialysis-related physical and psychological problems.

RELEVANCE TO CLINICAL PRACTICE

This study will contribute to perform of music intervention for haemodialysis-related physical and psychological problems for health professionals, particularly nurses.

STUDY REGISTRATION

This study has been registered at PROSPERO (Registration No. CRD42021267463).

Kidney Disease Symptoms before and after Kidney Transplantation

BACKGROUND AND OBJECTIVES

Patients with kidney failure report a high symptom burden, which likely increases while on dialysis due to physical and mental stressors and decreases after kidney transplantation due to restoration of kidney function.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We leveraged a two-center prospective study of 1298 kidney transplant candidates and 521 recipients (May 2014 to March 2020). Symptom scores (0-100) at evaluation and admission for transplantation were calculated using the Kidney Disease Quality of Life Short-Form Survey, where lower scores represent greater burden, and burden was categorized as very high: 0.0-71.0; high: 71.1-81.0; medium: 81.1-91.0; and low: 91.1-100.0. We estimated adjusted waitlist mortality risk (competing risks regression), change in symptoms between evaluation and transplantation (n=190), and post-transplantation symptom score trajectories (mixed effects models).

RESULTS

At evaluation, candidates reported being moderately to extremely bothered by fatigue (32%), xeroderma (27%), muscle soreness (26%), and pruritus (25%); 16% reported high and 21% reported very high symptom burden. Candidates with very high symptom burden were at greater waitlist mortality risk (adjusted subdistribution hazard ratio, 1.67; 95% confidence interval, 1.06 to 2.62). By transplantation, 34% experienced an increased symptom burden, whereas 42% remained unchanged. The estimated overall symptom score was 82.3 points at transplantation and 90.6 points at 3 months (10% improvement); the score increased 2.75 points per month (95% confidence interval, 2.38 to 3.13) from 0 to 3 months, and plateaued (-0.06 points per month; 95% confidence interval, -0.30 to 0.18) from 3 to 12 months post-transplantation. There were early (first 3 months) improvements in nine of 11 symptoms; pruritus (23% improvement) and fatigue (21% improvement) had the greatest improvements.

CONCLUSIONS

Among candidates, very high symptom burden was associated with waitlist mortality, but for those surviving and undergoing kidney transplantation, symptoms improved.

Exploring the Application of Interpretive Description in Chronic Illness: A Scoping Review

BACKGROUND AND PURPOSE

Chronic illness is a complex condition that affects over one billion people. To develop a deeper insight of the needs of this patient population, interpretive description uses disciplinary knowledge as the source of understanding. This methodology is a pragmatic approach to research without focusing on a strict methodological directive. The aims of this scoping review are twofold, (a) to describe the findings of studies that have used Thorne's interpretive description to research chronic illness and (b) to discuss the application of interpretive description in clinical research. Thereby, showing interpretive description as a valuable tool to advance nursing knowledge and patient care.

METHODS

The methodological framework for this review was based on the Johanna Briggs Institute guidelines for scoping reviews.

RESULTS

To develop an understanding of interpretive description, it is essential to examine the results of studies which have applied the methodology. Our scoping review showed that researchers utilizing interpretive description identified four common challenges experienced by individuals living with chronic illness: symptom management, education and knowledge, supportive care, and cultural disadvantages. By demonstrating how interpretive description is applied, it shows how it can be used to understand and interpret clinical phenomena to improve practice.

IMPLICATION FOR PRACTICE

This scoping review demonstrates how interpretive description was used to develop knowledge about chronic illness. The premise of interpretive description is that disciplinary knowledge offers a sufficient foundation to develop meaningful research to support health practices. By approaching research from a disciplinary perspective, new knowledge can be discovered to complex health problems.

The Knowledge and Educational Needs of Nurses Regarding Pain Management of Patients on Maintenance Hemodialysis: A Qualitative Study

Background:

Nurses are the first to encounter a patient in pain. A nurse’s knowledge of pain management in patients receiving hemodialysis allows them to provide optimal pain management.

Objective:

The aim of this qualitative study is to explore the experiences, perceptions, and beliefs of nurses in the hemodialysis unit regarding pain management practices and identify nurses’ educational needs to improve nurses’ pain management in practice.

Methods:

A purposive sample of 16 nurses working in four out-patient hemodialysis units in Amman, Jordan, was recruited. The data was collected through semi-structured interviews. The interviews were audio-recorded and transcribed manually for the following content analysis scheme.

Results:

The five themes and fifteen sub-categories were extracted from the nurses' experiences regarding nurses’ knowledge of pain management. The five categories that emerged from the analysis were (1) nurses’ knowledge of pain management, (2) nurses’ self-learning pain management strategy, (3) nurses’ approach to pain management, (4) patients continue to suffer unrelieved pain, (5) nurses’ educational needs.

Relevance to Clinical Practice:

This data will prove to be useful for evaluating pain management practices for patients on maintenance hemodialysis, developing educational programs for nurses working in hemodialysis units with a focus on improving pain management, and providing knowledge regarding these issues. More research is recommended among nurses for understanding pain knowledge in patients on maintenance hemodialysis.

Conclusion:

This qualitative analysis indicated that nurses are not fully aware of various strategies for pain management. Nurses’ perception of pain and pain management was found to be limited to pain assessment and some non-pharmacological management strategies. It has been revealed that nurses require educational interventions regarding pain management in practice.

Patient perspectives of target weight management and ultrafiltration in haemodialysis: a multi-center survey

Background

Decisions around planned ultrafiltration volumes are the only part of the haemodialysis prescription decided upon at every session. Removing too much fluid or too little is associated with both acute symptoms and long-term outcomes. The degree to which patients engage with or influence decision-making is not clear. We explored patient perspectives of prescribing ultrafiltration volumes, their understanding of the process and engagement with it.

Methods

A questionnaire developed for this study was administered to 1077 patients across 10 UK Renal Units. Factor analysis reduced the dataset into factors representing common themes. Relationships between survey results and factors were investigated using regression models. ANCOVA was used to explore differences between Renal Units.

Results

Patients generally felt in control of their fluid management and that they were given the final say on planned ultrafiltration volumes. Around half of the respondents reported they take an active role in their treatment. However, respondents were largely unable to relate signs and symptoms to fluid management practice and a third said they would not report common signs and symptoms to clinicians. A fifth of patients reported not to know how ultrafiltration volumes were calculated. Patients responded positively to questions relating to healthcare staff, though with significant variation between units, highlighting differences in perception of care.

Conclusions

Despite a lack of formal acknowledgement in fluid management protocols, patients have significant involvement in decisions regarding fluid removal during dialysis. Furthermore, substantial gaps remain in patient knowledge and engagement. Formalizing the role of patients in these decisions, including patient education, may improve prescription and achievement of target weights.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02399-7.

Patients' perspectives of pain in dialysis: systematic review and thematic synthesis of qualitative studies

ABSTRACT

Pain is a severe and common symptom in patients receiving dialysis but remains inadequately managed in clinical practice. Understanding patient experiences of pain can inform strategies to address this patient-important symptom. We aimed to describe patients' perspectives on causes, experiences, and impacts of dialysis-associated pain. MEDLINE, Embase, PsycINFO, and CINAHL were searched to August 2019 for all qualitative studies that described the perspectives of pain in adults aged 18 years or older receiving dialysis. Findings from the primary studies were analyzed using thematic synthesis. We included 60 studies across 14 countries involving 1343 participants (1215 receiving hemodialysis and 128 receiving peritoneal dialysis), and identified 6 themes: gripped by an all-consuming agony (draining cognitive capacity, exacerbating other symptoms); suffering in silence (surrendering to the inevitable, ignored or dismissed, hiding symptoms to protect others); provoking fear of treatment (resistance to cannulation, avoiding dialysis, anxious from witnessing other patients in pain); preventing life participation (preventing fulfilment of valued roles, depleting the will to live); coping aided by connection with others (shared understanding among patients, comforted and supported by others); and developing awareness, assertiveness, and self-reliance (procedural vigilance, finding strategies to minimize pain, bodily understanding and knowing thresholds, positive thinking). Struggling with pain in dialysis involved a progression of agony, fear, avoidance, and despair. However, support from others and self-management strategies were used to cope with pain. Strategies to empower patients to report and minimize pain and its consequences in dialysis are needed.

Suffering and Symptoms At the End of Life in ICU Patients Undergoing Renal Replacement Therapy

BACKGROUND

We know little about the end-of-life suffering and symptoms of intensive care unit (ICU) decedents in general and those who undergo renal replacement therapy (RRT) in particular.

OBJECTIVES

To examine differences in end-of-life suffering and various symptoms' contribution to suffering between ICU decedents who did not undergo RRT, those who underwent RRT for end-stage kidney disease (ESKD), and those who underwent RRT for acute kidney injury (AKI).

METHODS

This is a cross-sectional study conducted at a quaternary-level referral hospital September 2015-March 2017. Nurses completed interviews about ICU patients' suffering and symptoms in their final week. We dichotomized overall suffering into elevated and non-elevated and each symptom as contributing or not to a patient's suffering.

RESULTS

Sixty-four nurses completed interviews on 165 patients. Median patient age was 67 years (interquartile range 57, 78); 41% were female. In a multivariable model, undergoing RRT for AKI (odds ratio [OR] 2.95, 95% confidence interval [CI] 1.34-6.49) was significantly associated with elevated suffering compared to no RRT; undergoing RRT for ESKD was not. Adjusting for length of stay, AKI-RRT patients were more likely than non-RRT patients to have fecal incontinence (OR 2.21, 95% CI 1.00-4.93), painful broken skin (OR 2.41, 95% CI 1.14-5.12), and rashes (OR 3.61, 95% CI 1.35-9.67) contributing to their suffering.

CONCLUSIONS

Undergoing RRT for AKI was associated with elevated suffering in the last week of life in ICU decedents. Painful broken skin, rashes, and fecal incontinence were more likely to contribute to suffering in AKI-RRT patients than in non-RRT patients. How to reduce suffering associated with AKI-RRT in ICU patients merits further study.

A Mixed Methods Study of Symptom Experience in Patients With End-Stage Renal Disease

BACKGROUND

Patients with end-stage renal disease receiving dialysis experience a significant symptom burden. Identifying factors associated with this burden may improve symptom management. However, specific evidence about patients' experiences is lacking.

OBJECTIVES

The aim of this study was to explore factors that are associated with patients' symptom experiences.

METHODS

The convergent parallel mixed methods design was used. In the quantitative component, the Dialysis Symptom Index was used to assess the symptom burden of 271 participants to examine its associations with patient characteristics using correlation coefficients and multivariate regression analyses. In the qualitative component, associated factors reported by 10 participants were identified through semistructured interviews using content analysis. Assessments were conducted at enrollment, 6 months, and 12 months. After separate data analyses, findings were integrated using side-by-side comparison and joint display.

RESULTS

Several significant associations were identified between patient characteristics and symptom burden, and the participants described four categories of factors (i.e., treatment related, pathophysiological, situational, dietary) associated with a higher symptom burden during their interviews. Across both components of this study, three factors were consistent (i.e., employment, hyperphosphatemia, anemia). Participants described several factors not reported previously.

DISCUSSION

This study explored subjective and objective factors influencing the symptom experiences of patients with end-stage renal disease using a mixed methods design. These risk factors can be used to identify high-risk patients. Our findings suggest that participants relied on laboratory results and treatments to explain their symptom experiences. These findings suggest that assessment of both subjective and objective factors is needed to explore patients' symptom experiences.

Impact of chronic kidney diseases in feet health & quality of life: A case-series study

PURPOSE

The objective of this study is examine Quality of Life in subjects with chronic kidney disease utilizing Foot Health Status Questionnaire (FHSQ).

MATERIAL AND METHODS

101 subjects with chronic kidney disease (CKD) was studied in specialized clinics, in Extremadura (Spain). An observational descriptive study. The FHSQ was utilized to assess specific foot health (first section) and overall health (second division). The differences between clumps they were assessed using a t-test to independent samples.

RESULTS

59.40% (n = 60) were men and 40.59% (n = 41) women. The mean age was 68.77 ± 14.07. In first division of the FHSQ, a less score was registered in footwear domain (39.25) and in general foot health domain (46.37). In second division, less scores were resulted in general health domain (72) and vigour domain (60.43). CKD women got less scores in every domain. Women with CKD obtained significantly less scores in dimensions of foot pain, foot function, footwear, general foot health, general health and physical activity and there was no difference contrasted with men in the dimensions of social capacity and vigour.

CONCLUSIONS

The studied CKD population has problems their feet. Quality of life of CKD subjects is negatively impacted by health of their feet, difficulties with footwear, their overall health, and lack of vitality. Women with CKD show lower values of quality of life contrasted to male patients, associated with inability to perform physical activity, lack of energy and tiredness.

Patient-reported symptoms during dialysis: the effect of pre-dialysis extracellular water and change in extracellular water post-dialysis

Background

Quality of life for haemodialysis (HD) patients may be affected by symptoms during dialysis treatments, and patient groups have highlighted the need to improve post-dialysis fatigue and dialysis-related symptoms. As changes in extracellular water (ECW) may lead to cramps and other symptoms, we wished to determine whether there was an association between ECW and intra-dialytic symptoms.

Methods

We reviewed the hospital records of HD patients who completed a self-reported intra-dialytic symptom questionnaire, using a visual analogue scale, who had contemporaneous pre- and postdialysis bioimpedance ECW measurements adjusted to height (aECW).

Results

We studied dialysis sessions of 506 patients, 314 (62.1%) male, 226 (44.7%) diabetic, mean age 64.6 ± 15.7 years, weight 69.9 ± 17.4 kg, and duration of dialysis treatment 26 (9.6–60.1) months. We divided patients into three groups according to pre-dialysis aECW, and total dialysis symptom scores were greater for those in the lower tertile (25 (10–41) vs middle 18 (8.5–34) vs upper 20 (7–31), p < 0.05). Only feeling cold, dizziness, and low blood pressure were statistically different between the three pre-dialysis aECW groups, and there was no difference in post-dialysis recovery times.

We analysed the effect of the fall in aECW pre-to post-dialysis. Patients in the group with the greatest fall in aECW did not report more intra-dialytic symptoms or longer recovery times.

Conclusion

We found that patients starting dialysis with lower relative ECW were more likely to report intra-dialytic symptoms than those with greater amounts of fluid to remove, and most commonly reported symptoms were associated with intra-vascular volume depletion.

Patient experiences of sleep in dialysis: systematic review of qualitative studies

RATIONALE AND OBJECTIVE

Sleep problems affect more than half of patients receiving dialysis and are associated with increased risk of mortality, cardiovascular events, depression and impaired functioning and quality of life. Symptoms such as fatigue and exhaustion may be attributed to sleep problems or sleep disorders, as well as the burden of kidney disease and treatment. This study aims to describe the patient perspectives on the reasons, impact and management of sleep problems in dialysis.

STUDY DESIGN

Systematic review and thematic synthesis of qualitative studies that report patient experience and perspectives on sleep in dialysis.

SETTING AND POPULATION

Patients receiving dialysis.

SEARCH STRATEGY AND SOURCES

MEDLINE, Embase, PsycINFO, CINAHL, reference lists and PhD dissertations were searched from inception to August 2019.

DATA EXTRACTION

All text from the results/conclusion of the primary studies.

ANALYTICAL APPROACH

Thematic synthesis.

RESULTS

We included 48 studies involving 1156 participants from 16 countries. We identified six themes: dominating demands of treatment (with subthemes of: demanding and relentless schedule, regret for wasted time); scheduling and control (managing sleep routines, napping and nocturnal sleep disruption, meditative aids); disruptions due to dialysis (unsettled sleep, hypervigilance and worry); symptoms depriving sleep (difficulty falling asleep, constant waking); overwhelmed and without choice (futility of sleep, uncontrollable exhaustion, restlessness is irrepressible); and as a coping mechanism (avoiding anxiety, alleviating symptoms, combating boredom).

LIMITATIONS

Most studies were conducted in high-income, English-speaking countries.

CONCLUSION

The treatment and symptom burden of dialysis disrupts and deprives patients of sleep, which leads to overwhelming and uncontrollable exhaustion. Better management of symptoms and effective strategies to manage sleep routines may improve sleep quality for better overall health in patients receiving dialysis.

Feasibility of Tablet-Based Patient-Reported Symptom Data Collection Among Hemodialysis Patients

Introduction

Individuals receiving in-center hemodialysis have high symptom burdens but often do not report their symptoms to care teams. Evidence from other diseases suggest that use of symptom electronic patient-reported outcome measures (ePROMs) may improve outcomes. We assessed the usability of a symptom ePROM system and then implemented a quality improvement (QI) project with the objective of improving symptom communication at a US hemodialysis clinic. During the project, we assessed the feasibility of ePROM implementation and conducted a substudy exploring the effect of ePROM use on patient-centered care.

Methods

After conducting usability testing, we used mixed methods, guided by the Quality Implementation Framework, to implement a 16-week symptom ePROM QI project. We performed pre-, intra-, and postproject stakeholder interviews to identify implementation barriers and facilitators. We collected ePROM system-generated data on symptoms, e-mail alerts, and response rates, among other factors, to inform our feasibility assessment. We compared pre- and postproject outcomes.

Results

There were 62 patient participants (34% black, 16% Spanish-speaking) and 19 care team participants (4 physicians, 15 clinic personnel) at QI project start, and 32 research participants. In total, the symptom ePROM was administered 496 times (completion rate = 84%). The implementation approach and ePROM system were modified to address stakeholder-identified concerns throughout. ePROM implementation was feasible as demonstrated by the program’s acceptability, demand, implementation success, practicality, integration in care, and observed trend toward improved outcomes.

Conclusions

Symptom ePROM administration during hemodialysis is feasible. Trials investigating the effectiveness of symptom ePROMs and optimal administration strategies are needed.

A Qualitative Metasynthesis of the Experience of Fatigue Across Five Chronic Conditions

CONTEXT

Fatigue is a symptom reported by patients with a variety of chronic conditions. However, it is unclear whether fatigue is similar across conditions. Better understanding its nature could provide important clues regarding the mechanisms underlying fatigue and aid in developing more effective therapeutic interventions to decrease fatigue and improve quality of life.

OBJECTIVES

To better understand the nature of fatigue, we performed a qualitative metasynthesis exploring patients' experiences of fatigue across five chronic noninfectious conditions: heart failure, multiple sclerosis, rheumatoid arthritis, chronic kidney disease, and chronic obstructive pulmonary disease.

METHODS

We identified 34 qualitative studies written in the last 10 years describing fatigue in patients with one of the aforementioned conditions using three databases (Embase, PubMed, and CINAHL). Studies with patient quotes describing fatigue were synthesized, integrated, and interpreted.

RESULTS

Across conditions, patients consistently described fatigue as persistent overwhelming tiredness, severe lack of energy, and physical weakness that worsened over time. Four common themes emerged: running out of batteries, a bad life, associated symptoms (e.g., sleep disturbance, impaired cognition, and depression), and feeling misunderstood by others, with a fear of not being believed or being perceived negatively.

CONCLUSION

In adults with heart failure, multiple sclerosis, rheumatoid arthritis, chronic kidney disease, and chronic obstructive pulmonary disease, we found that fatigue was characterized by severe energy depletion, which had negative impacts on patients' lives and caused associated symptoms that exacerbated fatigue. Yet, fatigue is commonly misunderstood and inadequately acknowledged.

Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Blood pressure (BP) and volume control are critical components of dialysis care and have substantial impacts on patient symptoms, quality of life, and cardiovascular complications. Yet, developing consensus best practices for BP and volume control have been challenging, given the absence of objective measures of extracellular volume status and the lack of high-quality evidence for many therapeutic interventions. In February of 2019, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference titled Blood Pressure and Volume Management in Dialysis to assess the current state of knowledge related to BP and volume management and identify opportunities to improve clinical and patient-reported outcomes among individuals receiving maintenance dialysis. Four major topics were addressed: BP measurement, BP targets, and pharmacologic management of suboptimal BP; dialysis prescriptions as they relate to BP and volume; extracellular volume assessment and management with a focus on technology-based solutions; and volume-related patient symptoms and experiences. The overarching theme resulting from presentations and discussions was that managing BP and volume in dialysis involves weighing multiple clinical factors and risk considerations as well as patient lifestyle and preferences, all within a narrow therapeutic window for avoiding acute or chronic volume-related complications. Striking this challenging balance requires individualizing the dialysis prescription by incorporating comorbid health conditions, treatment hemodynamic patterns, clinical judgment, and patient preferences into decision-making, all within local resource constraints.

Educational or behavioural interventions for symptoms and health-related quality of life in adults receiving haemodialysis: A systematic review

BACKGROUND

People with end-stage kidney disease (ESKD) suffer from multiple symptoms, which have a negative impact on their health-related quality of life (HRQoL). Educational and behavioural interventions are being developed for this population; however, the effect of these interventions is unclear.

AIM

To evaluate the effectiveness of educational or behavioural interventions compared with standard care or alternative strategies on reducing symptoms and improving HRQoL in adults with ESKD receiving haemodialysis (HD).

METHODS

An effectiveness systematic review using Joanna Briggs Institute (JBI) procedures was conducted on experimental studies [randomised controlled trials (RCTs), pseudo-RCTs and quasi-experimental designs] published in English between January 2009 and July 2019. Studies were retrieved from CINAHL, PubMed, MEDLINE, Embase, PsycINFO, Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trial) and JBI databases. Effect size at 95% confidence interval was calculated where possible.

RESULTS

Eighteen studies involving 791 participants were included in this review. All studies involved behavioural interventions with the majority of studies (n = 11) targeting psychological symptoms. Interventions were categorised as either active or passive. Active interventions seemed to improve some physical symptoms, although there was very little evidence of improvements to HRQoL. Passive interventions tended to have a large effect on psychological symptoms and the mental health components of HRQoL.

CONCLUSION

Due to great heterogeneity between studies, meta-analyses could not be conducted further limiting the evidence to inform practice. In addition, further research on educational interventions to teach self-management strategies for symptom management and to improve HRQoL in people with ESKD receiving HD are needed.

Transcultural adaptation of the Thirst Distress Scale (TDS) into Brazilian Portuguese and an analysis of the psychometric properties of the scale for patients on hemodialysis

OBJECTIVE

To produce a transcultural adaptation of the Thirst Distress Scale (TDS) into Brazilian Portuguese and analyze the scale's psychometric properties for patients on hemodialysis (HD).

METHODS

The original scale was translated, back translated, and discussed with psychometric assessment experts. The final version was tested with 126 patients on HD and retested with 70 individuals from the original patient population. Cronbach's alpha was used to measure the scale's internal consistency. Reliability of thirst intensity evaluated via the visual analogue scale (VAS) was tested with Kappa statistic and the Bland-Altman plot. Reproducibility was assessed based on the intraclass correlation coefficient (ICC).

RESULTS

The wording of three items and the verb tenses of six had to be adjusted in the final version of the Brazilian Portuguese TDS. Comprehension of the scale by patients on HD was good, the scale's internal consistency was satisfactory (0.84; p<0.001), agreement with a visual analogue scale (VAS) was moderate (kappa=0.44; p<0.001), and reproducibility neared perfection (ICC=0.87; p<0.001).

CONCLUSION

Our results showed that the Brazilian Portuguese version of the scale might be used reliably. The Brazilian Portuguese version of the TDS is a practical, affordable, accessible and well-accepted tool that has a lot to offer for the management of patients with HD.

Factors affecting depressive symptoms in employed hemodialysis patients with chronic renal failure

Depressive symptoms are commonly experienced by hemodialysis patients, generally related to withdrawal from dialysis and compliance with dialysis prescription. This study aimed to identify the factors affecting depressive symptoms in employed hemodialysis patients with chronic renal failure. A cross-sectional, correlational study design was utilized, consisting of 71 patients with chronic renal failure receiving hemodialysis treatment, all employed. Depressive symptoms were assessed by the Center for Epidemiologic Studies Depression Scale (CES-D) and fatigue by the Chalder Fatigue Scale. Psychosocial adaptation was measured by the Korean version of the Social Profile. In this study, 32.4% of the participants were depressed. Female patients had a higher score for depressive symptoms than males (25.78 ± 10.15 vs. 16.42 ± 10.25, p = .013). Mental fatigue (β = .425, p < .001), psychosocial adaptation (β = -.275, p < .001), and subjective health (β = -.199, p < .05) were predictive variables of depressive symptoms in hemodialysis patients, with mental fatigue being the most important factor. Depressive symptoms can affect the self-management of hemodialysis patients; therefore, it is important that healthcare providers identify factors that affect depressive symptoms, particularly those associated with mental fatigue.

Perspectives on symptom experiences and symptom reporting among individuals on hemodialysis

Background

Individuals on hemodialysis bear substantial symptom burdens, but providers often underappreciate patient symptoms. In general, standardized, patient-reported symptom data are not captured during routine dialysis care. We undertook this study to better understand patient experiences with symptoms and symptom reporting. In exploratory interviews, we sought to describe hemodialysis nurse and patient care technician perspectives on symptoms and symptom reporting.

Methods

We conducted semi-structured interviews with 42 US hemodialysis patients and 13 hemodialysis clinic personnel. Interviews were conducted between February and October 2017 and were analyzed using thematic analysis.

Results

Seven themes were identified in patient interviews: (i) symptoms engendering symptoms, (ii) resignation that life is dependent on a machine, (iii) experiencing the life intrusiveness of dialysis, (iv) developing adaptive coping strategies, (v) creating a personal symptom narrative, (vi) negotiating loss of control and (vii) encountering the limits of the dialysis delivery system. Overall, patient symptom experiences and perceptions appeared to influence symptom-reporting tendencies, leading some patients to communicate proactively about symptoms, but others to endure silently all but the most severe symptoms. Three themes were identified in exploratory clinic personnel interviews: (i) searching for symptom explanations, (ii) facing the limits of their roles and (iii) encountering the limits of the dialysis delivery system. In contrast to patients, clinic personnel generally believed that most patients were inclined to spontaneously report their symptoms to providers.

Conclusions

Interviews with patients and dialysis clinic personnel suggest that symptom reporting is highly variable and likely influenced by many personal, treatment and environmental factors.

Association between fatigue, motivational measures (BIS/BAS) and semi-structured psychosocial interview in hemodialytic treatment

Background

Nowadays there is a growing interest in exploring causes of fatigue symptoms and the possible linked aspects in patients with Chronic Kidney Disease (CKD) receiving hemodialysis (HD) treatment. Inflammatory processes were demonstrated to influence motivational systems functioning in chronic conditions. However, there is a lack of connection between quantitative motivational systems measure and patients self-report motivational and fatigue issue. Thus, the aim of this study was to identify an association between HD patients reward mechanisms, fatigue severity and psychosocial variables emerging from semi-structured interviews.

Methods

Interviews were held for a sample of ninety-four patients (54 males, 40 females; M_age = 62.98 ± 17.94; dialytic mean age in months = 76.55 ± 84.89) receiving chronic HD treatment and consequently analyzed by means of quantitative and qualitative analysis. Behavioral motivation systems reflecting inhibition/approach tendency to rewards were measured by Behavioral Inhibition/Activation System (BIS/BAS) scale and the fatigue severity experienced by HD patients was measured with the Fatigue Severity Scale. Scale results were correlated to psychosocial variables and topics derived from the semi-structured interviews.

Results

Findings highlight the presence of two effects: one related to the Behavioral Activation System (BAS) as a protective factor against the HD treatment pervasive consequences; the other one deals with the self-reported levels of fatigue that seemed to significantly interfere with patients’ daily life, as a function of gender.

Conclusions

Such results encourage the use of a mixed method approach to understand the complexity of the subjective experience of patients’ facing chronic disease and treatments.

Envolvimento da pessoa com doença renal crônica em seus cuidados: revisão integrativa

Resumo A doença renal crônica (DRC) acarreta ao indivíduo uma sobrecarga de cuidados indispensáveis ao alcance das metas terapêuticas e qualidade de vida. O controle nutricional, o regime medicamentoso e as terapias de substituição renal são exemplos que requerem participação ativa. Assim, foi realizada revisão integrativa de artigos científicos para identificar os que versam sobre envolvimento e participação do paciente em seus cuidados na DRC. Os descritores “Chronic kidney disease”; “Self-Care” and “Patient Participation” foram aplicados nas bases CINHAL, Bireme e Medline. Selecionamos 21 publicações entre 2012 e 2016. A entrevista semiestruturada destacou-se como método de coleta de dados, com a aplicação da análise temática fenomenológica. Conforme a predominância do assunto tratado, os manuscritos foram alocados em quatro eixos temáticos: Manejo da doença renal e seu tratamento; Envolvimento na tomada de decisão; Plano avançado de cuidados; e, Diálise peritoneal domiciliar. Verificamos que abordagens envolvendo pessoas transplantadas ou nos primeiros estágios da doença são pouco explorados com a aplicação do método qualitativo e, ainda, consideramos que pessoas com DRC devem ser instigadas no envolvimento ativo de seus próprios cuidados, necessitando de conhecimento, motivação e suporte dos profissionais de saúde.

Fostering Innovation in Symptom Management among Hemodialysis Patients: Paths Forward for Insomnia, Muscle Cramps, and Fatigue

Individuals receiving in-center maintenance hemodialysis bear a high burden of both physical and mood symptoms. More than half of patients on hemodialysis report sleep disturbance, muscle cramps, and fatigue. Patients describe symptoms as having a deleterious effect on their quality of life, suggesting that symptom alleviation may meaningfully improve patient-reported outcomes. Moreover, patients on hemodialysis have identified symptom management as a key area for research and innovation, prioritizing symptom alleviation over other health outcomes such as mortality and biochemical indices. Despite the importance of symptoms to patients, there has been little research explicitly geared toward improving patient symptoms, and therefore minimal innovation in symptom management. In general, the physiologic underpinnings of symptoms are poorly understood, hampering the development of targeted therapies. In fact, there have been few drugs or devices approved by the US Food and Drug Administration for the indication of improving any patient-reported outcomes for patients on hemodialysis. Recognizing this gap in innovation, the Kidney Health Initiative, a public-private partnership between the American Society of Nephrology and US Food and Drug Administration, convened a workgroup to first prioritize symptoms for the development of therapeutic interventions, and then identify near-term actionable research goals for the prioritized physical symptoms of insomnia, muscle cramps, and fatigue. This paper summarizes the pathophysiology of the three prioritized symptoms, identifies key knowledge gaps, acknowledges factors that challenge development of new therapies, and offers the nephrology community actionable research goals for insomnia, muscle cramps, and fatigue.

Development and content validity of a hemodialysis symptom patient-reported outcome measure

PURPOSE

To describe the process and preliminary qualitative development of a new symptom-based patient-reported outcome measure (PROM) intended to assess hemodialysis treatment-related physical symptoms.

METHODS

Experienced interviewers conducted concept elicitation and cognitive debriefing interviews with individuals receiving in-center hemodialysis in the United States. Concept elicitation interviews involved eliciting spontaneous reports of symptom experiences and probing to further explore and confirm concepts. We used patient-reported concepts to generate a preliminary symptom PROM. We conducted 3 rounds of cognitive debriefing interviews to evaluate symptom relevance, item interpretability, and draft item structure. We iteratively refined the measure based on cognitive interview findings.

RESULTS

Forty-two adults receiving in-center hemodialysis participated in the concept elicitation interviews. A total of 12 symptoms were reported by > 10% of interviewees. We developed a 13-item initial draft instrument for testing in 3 rounds of cognitive interviews with an additional 52 hemodialysis patients. Participant responses and feedback during cognitive interviews led to changes in symptom descriptions, division of the single item "nausea/vomiting" into 2 distinct items, removal of daily activity interference items, addition of instructions, and clarification about the recall period, among other changes.

CONCLUSIONS

Symptom Monitoring on Renal Replacement Therapy-Hemodialysis (SMaRRT-HD™) is a 14-item PROM intended for use in hemodialysis patents. SMaRRT-HD™ uses a single treatment recall period and a 5-point Likert scale to assess symptom severity. Qualitative interview data provide evidence of its content validity. SMaRRT-HD™ is undergoing additional testing to assess measurement properties and inform measure scoring.

Work of being an adult patient with chronic kidney disease: a systematic review of qualitative studies

INTRODUCTION

Chronic kidney disease (CKD) requires patients and caregivers to invest in self-care and self-management of their disease. We aimed to describe the work for adult patients that follows from these investments and develop an understanding of burden of treatment (BoT).

METHODS

Systematic review of qualitative primary studies that builds on EXPERTS1 Protocol, PROSPERO registration number: CRD42014014547. We included research published in English, Spanish and Portuguese, from 2000 to present, describing experience of illness and healthcare of people with CKD and caregivers. Searches were conducted in MEDLINE, Embase, CINAHL Plus, PsycINFO, Scopus, Scientific Electronic Library Online and Red de Revistas Científicas de América Latina y el Caribe, España y Portugal. Content was analysed with theoretical framework using middle-range theories.

RESULTS

Searches resulted in 260 studies from 30 countries (5115 patients and 1071 carers). Socioeconomic status was central to the experience of CKD, especially in its advanced stages when renal replacement treatment is necessary. Unfunded healthcare was fragmented and of indeterminate duration, with patients often depending on emergency care. Treatment could lead to unemployment, and in turn, to uninsurance or underinsurance. Patients feared catastrophic events because of diminished financial capacity and made strenuous efforts to prevent them. Transportation to and from haemodialysis centre, with variable availability and cost, was a common problem, aggravated for patients in non-urban areas, or with young children, and low resources. Additional work for those uninsured or underinsured included fund-raising. Transplanted patients needed to manage finances and responsibilities in an uncertain context. Information on the disease, treatment options and immunosuppressants side effects was a widespread problem.

CONCLUSIONS

Being a person with end-stage kidney disease always implied high burden, time-consuming, invasive and exhausting tasks, impacting on all aspects of patients' and caregivers' lives. Further research on BoT could inform healthcare professionals and policy makers about factors that shape patients' trajectories and contribute towards a better illness experience for those living with CKD.

PROSPERO REGISTRATION NUMBER

CRD42014014547.

Lived experiences of patients on hemodialytic treatment: A discursive perspective on fatigue and motivational issues

Fatigue is an incapacitating symptom for patients on chronic hemodialysis treatment. This study explored the relationship between hemodialysis patients' subjective experience and motivation. The investigation of patients' narratives and fatigue-related factors was performed by holding semi-structured interviews with 31 hemodialysis patients. Fatigue Severity Scale and Behavioral Inhibition/Activation System questionnaire were used to assess fatigue severity and motivational mechanisms. Results showed significant differences in the use of specific topics and words (such as "family," "to manage," "dialysis," "psychological issues") depending on high, medium, and low Behavioral Inhibition System, Behavioral Activation System, and Fatigue Severity Scale scores, indicating that hemodialysis patients' narratives contain keywords related to the motivational sphere.

Symptom Prioritization among Adults Receiving In-Center Hemodialysis: A Mixed Methods Study

BACKGROUND AND OBJECTIVES

Individuals receiving in-center hemodialysis experience a high symptom burden that detrimentally affects their quality of life. There are few evidence-based interventions for symptom relief in this population. To stimulate innovation in symptom management, data on patient symptom prioritization and treatment preferences are needed. We undertook this study to (1) identify patient-prioritized symptoms for the development of symptom relief therapies and (2) elicit preferences for treatments among individuals receiving hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a mixed methods study that included focus groups in Carrboro, North Carolina; Tucson, Arizona; and Seattle, Washington and a nationally distributed online survey. Focus group transcripts were analyzed for patterns, and the highest priority symptoms were determined on the basis of frequency and report severity. We used focus group findings to inform survey items. Focus group and survey results were crossvalidated and synthesized for final symptom prioritization.

RESULTS

There were 32 participants across three focus groups and 87 survey respondents from 27 states in the United States. The physical symptoms of insomnia, fatigue, muscle cramping, and nausea/vomiting and the mood symptoms of anxiety and depressed mood were reported by participants in all focus groups. Among survey respondents, fatigue (94%), cramping (79%), and body aches (76%) were the most common physical symptoms, and feeling depressed (66%), worried (64%), and frustrated (63%) were the most common mood symptoms. The top-prioritized symptoms were consistent across focus group and survey participants and included the physical symptoms insomnia, fatigue, and cramping and the mood symptoms anxiety, depression, and frustration. Participants indicated that symptom frequency, duration, unpredictability, and social and financial effects factored most heavily into symptom prioritization.

CONCLUSIONS

Patients prioritized the physical symptoms of insomnia, fatigue, and cramping and the mood symptoms of anxiety, depression, and frustration as the top symptoms for which to find new therapies.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent urine abnormalities, structural abnormalities or impaired excretory renal function suggestive of a loss of functional nephrons. The majority of patients with CKD are at risk of accelerated cardiovascular disease and death. For those who progress to end-stage renal disease, the limited accessibility to renal replacement therapy is a problem in many parts of the world. Risk factors for the development and progression of CKD include low nephron number at birth, nephron loss due to increasing age and acute or chronic kidney injuries caused by toxic exposures or diseases (for example, obesity and type 2 diabetes mellitus). The management of patients with CKD is focused on early detection or prevention, treatment of the underlying cause (if possible) to curb progression and attention to secondary processes that contribute to ongoing nephron loss. Blood pressure control, inhibition of the renin-angiotensin system and disease-specific interventions are the cornerstones of therapy. CKD complications such as anaemia, metabolic acidosis and secondary hyperparathyroidism affect cardiovascular health and quality of life, and require diagnosis and treatment.