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

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.

Usefulness of assessment of the Clinical Frailty Scale and the Dementia Assessment Sheet for Community-based Integrated Care System 21-items at the time of initiation of maintenance hemodialysis in older patients with chronic kidney disease

INTRODUCTION

We examined whether the Clinical Frailty Scale (CFS), a widely adopted tool for stratifying the degree of frailty, and the Dementia Assessment Sheet for Community-based Integrated Care System 21-items (DASC-21), a simple tool for simultaneous assessment of impaired cognition and impaired ADL, at the time of initiation of hemodialysis is useful tool of older patients for the outcome and prognosis.

METHODS

Data for 101 patients aged 75 years or older (mean age, 84.3 years) with ESRD who were initiated on hemodialysis and could be followed up for a period of 6 months were reviewed.

RESULTS

The 6-month survival curves showed a significantly higher number of deaths in the frailty (CFS≥5) group than in the normal to vulnerable (CFS<5) group (p<0.01). The CFS level was also significantly higher (6.5±1.5) in patients who died within 6 months of dialysis initiation as compared with that (4.6±1.7) in patients who survived (p<0.01). On the other hand, the total score of DASC-21 was related to need for inpatient maintenance dialysis (p<0.01). The total score on the DASC-21 were found as showing significant correlations with the CFS level. The IADL outside the home was identified in the DASC-21 sub-analyses as being correlated with CFS.

CONCLUSIONS

The CFS and the DASC-21 appeared to be a useful predictive tool of outcome and prognosis for older patients being initiated on hemodialysis. Assessment by the CFS or the DASC-21 might be useful for selecting the renal replacement therapy by shared decision-making and for advance care planning.

Evaluation of risk factors related to sleep disorders in patients undergoing hemodialysis using a nomogram model

This study aimed to investigate the risk factors related to sleep disorders in patients undergoing hemodialysis using a nomogram model. A cross-sectional survey was conducted in a hospital in Zhejiang province, China from January 1, 2020, to November 31, 2022 among patients undergoing hemodialysis. Dietary intake was assessed applying a Food Frequency Questionnaire. Sleep quality was evaluated by the Pittsburgh Sleep Quality Index. Evaluation of risk factors related to sleep disorders in patients undergoing hemodialysis was using a nomogram model. This study included 201 patients and 87 individuals (43.3%, 87/201) exhibited sleep disorders. The average age of included patients was 51.1 ± 9.0 years, with males accounting for 55.7% (112/201). Results from nomogram model exhibited that potential risk factors for sleep disorders in patients undergoing hemodialysis included female, advanced age, increased creatinine and alanine aminotransferase levels, as well as higher red meat consumption. Inversely, protective factors against sleep disorders in these patients included higher consumption of poultry, fish, vegetables, and dietary fiber. The C-index demonstrated a high level of discriminative ability (0.922). This study found that age, sex, and dietary factors were associated with sleep disorders in hemodialysis patients. Hemodialysis patients with sleep disorders require urgent dietary guidance.

Economic evaluation of dialysis and comprehensive conservative care for chronic kidney disease using the ICECAP-O and EQ-5D-5L; a comparison of evaluation instruments

BACKGROUND

Chronic Kidney Disease (CKD) patients often require long-term care, and while Hemodialysis (HD) is the standard treatment, Comprehensive Conservative Care (CCC) is gaining popularity as an alternative. Economic evaluations comparing their cost-effectiveness are crucial. This study aims to perform a cost-utility analysis comparing HD and CCC using the EQ-5D-5L and ICECAP-O instruments to assessing healthcare interventions in CKD patients.

METHODS

This short-term economic evaluation involved 183 participants (105 HD, 76 CCC) and collected data on demographics, comorbidities, laboratory results, treatment costs, and HRQoL measured by ICECAP-O and EQ-5D-5L. Incremental Cost-Effectiveness Ratios (ICERs) and Net Monetary Benefit (NMB) were calculated separately for each instrument, and Probabilistic Sensitivity Analysis (PSA) assessed uncertainty.

RESULTS

CCC demonstrated significantly lower costs (mean difference $8,544.52) compared to HD. Both EQ-5D-5L and ICECAP-O indicated higher Quality-Adjusted Life Years (QALYs) for both groups, but the difference was not statistically significant (p > 0.05). CCC dominated HD in terms of HRQoL measures, with ICERs of -$141,742.67 (EQ-5D-5L) and -$4,272.26 (ICECAP-O). NMB was positive for CCC and negative for HD, highlighting its economic feasibility.

CONCLUSION

CCC proves a preferable and more cost-effective treatment option than HD for CKD patients aged 65 and above, regardless of the quality-of-life measure used for QALY calculations. Both EQ-5D-5L and ICECAP-O showed similar results in cost-utility analysis.

Kidney Supportive Care for Working-Age Adults with Chronic Kidney Disease: A Profile of Characteristics and Symptom Burden

INTRODUCTION

Chronic kidney disease (CKD) affects people across their lifespan. Kidney supportive care (KSC) is typically offered for older people for symptom management, education, and/or advance care planning (ACP). However, younger people may also benefit from KSC. This study sought to explore characteristics of working-age adults with CKD accessing KSC.

METHODS

Using a cross-sectional design, working-age adults (18-64 years) with CKD referred to a KSC service from February 2016 to July 2021 were included. Demographic and clinical data were extracted from patients' hospital records. Self-reported symptoms (Integrated Palliative Care Outcome Scale renal [IPOS-renal]) and health-related quality of life (European quality of life [EQ-5D-5L]) were assessed. Reasons for referral to KSC, kidney replacement therapy (KRT) pathway at referral, and comorbidity calculated using the Charlson Comorbidity Index were also assessed.

RESULTS

One Hundred Fifty-six working-age adults attended the KSC service. Median age was 57 years, with more than half receiving KRT. Weakness (92.2%), poor mobility (83.3%), and pain (82.5%) were the most prevalent and severe symptoms. The majority were referred for symptom management (n = 83, 53.2%) and 27% for ACP (n = 42). The ACP completion rate was low (28.9%). Those on dialysis had significantly higher symptom scores than those not receiving dialysis (p < 0.05).

CONCLUSION

Working-age adults with CKD experience a significant and debilitating symptom burden and need to consider options for treatment. This study provides new understanding about working-age adults with CKD that may help provide the specific support needed to meet their end-of-life care needs.

Quality of life in advanced renal disease managed either by haemodialysis or conservative care in older patients

OBJECTIVE

Consideration of quality of life (QoL) in people with end-stage renal disease has become an important part of treatment decision-making. The aim of this study was to report on QoL and other functional outcomes in patients with advanced chronic kidney disease (CKD).

METHOD

This was a cross-sectional study. Two samples of older patients (>60 years old) either conservatively managed (CM) or receiving hospital-based haemodialysis (HD), compared Kidney Disease Quality of Life (KDQoL-36) outcomes.

RESULTS

Data from 263 CM patients (CKD 4 n=188, mean age 73.6 years, 48 women; CKD 5 n=75, mean age 74.4 years, 26 women) and 74 patients on HD (mean age 73.8 years, 24 women) were analysed. Significant group differences were identified for two subscales of KDQoL-36. Symptoms/Problems List subscale was significantly better for those receiving HD compared with those CM with CKD 5 (p=<0.001). Symptom/Problem List scores of CM CKD stage 4 patients were not significantly different compared with HD patients but were significantly better than CM CKD stage 5 patients (p<0.001). Burden of Kidney Disease subscale was significantly better for both CKD 4 (p<0.001) and CKD 5 (p<0.001) CM patients when compared with those receiving HD.

CONCLUSION

Symptoms of advanced CKD significantly impact QoL for patients CM with CKD stage 5. Conversely, QoL is significantly impacted for those in receipt of HD due to the burden of treatment. These findings provide evidence for the use of QoL tools to help with clinical prognostication in advanced CKD. Using QoL tools will ensure specialist support is available for appropriate management of patients with CKD.

Association of exposure to multiple serum metals with the risk of chronic kidney disease in the elderly: a population-based case-control study

In the world, chronic kidney disease (CKD) has been recognized as one of the critical public health problems, and the prevalence is higher in the elderly people. However, there are few studies on the association between exposure to multiple serum metal levels and CKD. A case-control study, we established, for elderly people in Anhui Province, China, to explore the effects of different metals and analyze the effect of mixed exposure on CKD. In this study, 287 cases of CKD and 287 controls were selected in the elderly health physical examination project in Tongling City, Anhui Province. Questionnaire survey, physical examination, and blood collection were conducted. Graphite furnace atomic absorption spectrometry (GFAAS) and inductively coupled plasma optical emission spectrometry (ICP-OES) were used to measure the concentration of serum metals. After selecting by least absolute shrinkage and selection operator (LASSO), 5 metals were brought into the multi-metal model. After adjusting all potential covariates additionally, the concentrations of lead (Pb), cadmium (Cd), cobalt (Co), and manganese (Mn) were significantly associated with CKD risk, whereas Pb, Se, and Cd had significant non-linearity with CKD. Besides, patients with highest quartiles of cobalt (Co), lead (Pb), and manganese (Mn) were 1.64, 1.39, and 0.64 times more possible to have CKD, respectively, as compared with the lowest levels. In the Bayesian kernel machine regression (BKMR) model, cadmium (Cd) had a combined effect with lead (Pb) possibly. This study suggested that the CKD risk was associated with exposure of multiple metals in elderly people. The underlying mechanisms of serum metals and CKD need more experimental and prospective studies to elucidate.

Economic evaluation of three dialysis methods in patients with end-stage renal disease in China

OBJECTIVES

End-stage renal disease (ESRD) may result in different degrees of physical and psychological pain. Automated peritoneal dialysis (APD), continuous ambulatory peritoneal dialysis (CAPD), and hemodialysis (HD) as the main treatment methods lead to a heavy burden on social economic and family financial. However, there are few studies on the economic evaluation of the three dialysis methods in China.

METHODS

Cost-effectiveness analyses were performed using Markov models based on longitudinal data for 15 years of different modalities in Kunshan City, China. Direct cost derived from medical insurance information system, and indirect cost referred to as loss of productivity. Sensitivity analyses were conducted to study uncertainty.

RESULTS

The per capita total cost of CAPD was 664,027.00 yuan, the per capita utility is 5.9105. The per capita total cost of APD was 858,800.65 yuan, the per capita utility is 6.4548. The per capita total cost of HD was 1,281,213.64 yuan, the per capita utility is 6.1356. When CAPD was compared with HD, Incremental Cost-Effectiveness Ratio (ICER) was 1,323,389.53 yuan per QALY, compared with APD, ICER was 357,848.13 yuan per QALY. ICER value suggests that APD was cost-effective compared with CAPD and HD at a willingness-to-pay threshold of 538,200 yuan.

CONCLUSION

Our research showed that APD is the most appropriate and HD is the worst in terms of cost-effectiveness. However, in fact, HD accounts for a high proportion in China, so some relevant policy suggestions need to be implemented to change the current situation.

Five-Year Symptom Trajectories in Nondialysis-Dependent CKD Patients

BACKGROUND AND OBJECTIVES

Late stages of CKD are characterized by significant symptom burden. This study aimed to identify subgroups within the 5-year trajectories of symptom evolution in patients with CKD and to describe associated patient characteristics and outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 2787 participants (66% men) with eGFR <60 ml/min per 1.73 m2 enrolled in the CKD-Renal Epidemiology and Information Network (CKD-REIN) cohort study from July 2013 to May 2016, we assessed symptoms annually using the Kidney Disease Quality of Life-36 (KDQOL-36) questionnaire until December 2020. A total of 9121 measures were reported over follow-up; all participants had symptoms scored for at least one time point. We used a joint latent class-mixed model to distinguish profiles of symptom trajectories.

RESULTS

Patient mean age (±SD) at baseline was 67±13 years, and mean eGFR was 33±13 ml/min per 1.73 m2. The prevalence of each symptom ranged from 24% (chest pain) to 83% (fatigue), and 98% of participants reported at least one symptom. After a median (interquartile range) follow-up of 5.3 (3.4-6.0) years, 690 participants initiated KRT, and 490 died before KRT. We identified two profiles of symptom trajectories: a "worse symptom score and worsening trajectory" in 31% of participants, characterized by a low initial symptom score that worsened more than ten points over time, and a "better symptom score and stable trajectory" in 69% of participants, characterized by a high initial score that remained stable. Participants in the worse symptom score and worsening trajectory group had more risk factors for CKD progression at baseline, worse quality of life, and a higher risk of KRT and death before KRT than other participants.

CONCLUSIONS

This study highlights a significant worsening of symptoms in about one third of the participants, whereas the majority reported low symptom severity throughout the study.

Quality of Life in Patients with Chronic Kidney Disease Managed with or without Dialysis: An Observational Study

Background

Emerging research suggests that quality of life (QOL) outcomes, such as maintenance of independence, rather than length of life, are the main priority for many patients with end stage kidney disease (ESKD). There is therefore a need to focus on whether QOL for older patients on dialysis differs significantly from conservative kidney management (CKM). This study aimed to describe the QOL trajectory for patients with ESKD, comparing CKM to dialysis and transplantation.

Methods

This retrospective, observational study included all patients who attended the Kidney Supportive Care Clinic at St. George Hospital and had one or more EuroQOL (EQ5D5L) questionnaires between July 2014 and May 2020. Kruskal-Wallis tests compared QOL scores between groups at baseline and 12 months. Wilcoxon signed rank tests compared QOL scores from baseline to 18 months within groups. Chi-squared tests compared proportions of patients reporting problems with QOL "domains" between the groups at baseline and 12 months. McNemar's tests compared changes in proportions of patients reporting problems with QOL "domains" within groups from baseline to 12 months.

Results

A total of 604 patients had an initial survey. At baseline, patients who were managed conservatively reported more problems with mobility, self-care, and ability to perform usual activities. However, pain/discomfort and anxiety/depression were no higher in the conservative population. CKM patients reported no significant decline in mobility, self-care, ability to perform their usual activities, pain/discomfort, or anxiety/depression after 12 months or in QOL scores after 18 months compared with the other groups.

Conclusions

QOL scores or symptom burdens did not change significantly in patients receiving CKM compared with dialysis, suggesting that appropriately supported CKM can maintain patients' QOL.

Análisis del tratamiento conservador en el paciente con enfermedad renal crónica terminal. Revisión sistemática

Introducción: Desde hace unos años, debido a la inclusión de pacientes con enfermedad renal crónica cada vez más mayores en tratamiento renal sustitutivo, se viene ofreciendo como otra opción, tratamiento renal conservador, con resultados similares en algunas series al tratamiento dialítico.Objetivo: Revisar la literatura científica existente sobre el tratamiento renal conservador en pacientes con enfermedad renal crónica, su supervivencia y calidad de vida.Metodología: Se ha llevado a cabo una revisión sistemática. Se realizó una búsqueda en las bases de datos PubMed, ProQuest, Scielo y Scopus. Se incluyeron artículos científicos en español e inglés, y texto completo disponible. Se analizaron aquellos artículos que trataban sobre pacientes renales en estadío final de la enfermedad renal crónica terminal, tratados con tratamiento paliativo únicamente o en comparación con el tratamiento renal sustitutivo.Resultados: Se han incluido 15 artículos publicados entre los años 2010 y 2020. La enfermedad renal crónica es un problema de alta prevalencia en nuestra población, lo cual condiciona los tratamientos sustitutivos de la función renal. El tratamiento renal conservador surge como opción al sustitutivo, en aquellos pacientes mayores o con una corta expectativa de vida. Como factores más importantes a tener en cuenta surgen la supervivencia y la calidad de vida.Conclusiones: En el paciente con enfermedad renal crónica en tratamiento renal sustitutivo la supervivencia es mayor, aunque con peor calidad de vida, mientras que en el caso del tratamiento renal conservador suele ser al contrario. En pacientes mayores de 75-80 años la supervivencia se iguala, siendo necesario potenciar la calidad de vida y paliar los síntomas de la enfermedad

Using Human-Centered Design Principles to Create a Decision Aid on Conservative Kidney Management for Advanced Kidney Disease

Background

Most patients are unaware of approaches to treating advanced chronic kidney disease (CKD) other than dialysis.

Methods

We developed a dedicated decision aid on conservative kidney management using human-centered design principles in three phases: (1) discovery: engagement of informants to understand their needs and preferences; (2) design: multiple rapid cycles of ideation, prototyping, and testing of a decision aid with a small group of informants; and (3) implementation: testing the decision aid in real-world settings with attention to how the decision aid can be further refined. Informants included a national patient advisory committee on kidney diseases, 50 patients with stage 4 or 5 CKD and 35 of their family members, and 16 clinicians recruited from the greater Seattle area between June 2019 and September 2021.

Results

Findings from the discovery phase informed an initial prototype of the decision aid, which included five sections: a description of kidney disease and its signs and symptoms, an overview of conservative kidney management and the kinds of supports provided, self-reflection exercises to elicit patients' values and goals, the pros and cons of conservative kidney management, and the option of changing one's mind about conservative kidney management. The prototype underwent several rounds of iteration during its design phase, which resulted in the addition of an introductory section describing the intended audience and more detailed information in other sections. Findings from its implementation phase led to the addition of examples of common questions that patients and family members had about conservative kidney management and a final section on other related educational resources.

Conclusions

Human-centered design principles supported a systematic and collaborative approach between researchers, patients, family members, and clinicians for developing a decision aid on conservative kidney management.

Volunteering Experience among Older Adults with End-stage Renal Disease (ESRD)

Living with End-stage Renal Disease (ESRD) can be stressful and associated with long-term psychological effects on older adults, especially when they have to undergo a lifetime treatment. Previous studies have documented numerous positive effects of volunteering as a potential intervention on health and well-being among older adults. However, there is limited understanding of the experience of older adults in volunteering while having ESRD. This study aimed to explore the experience often older adults with ESRD volunteering while battling with their illness. Several themes emerged from the data analysis regarding the experience of volunteerism among the older adult ESRD patients. The themes are pre-volunteerism experience, enriching and inspiring experience, volunteering experience as sources of support system, improvement of health and wellbeing experience, experience in discovering meaning in life, experience in repaying the good deed, and challenges in volunteerism participation. This study contributes to the literature and practices through the illumination of innovative intervention through volunteering for older adults with ESRD.

Long-term Outcomes Among Patients With Advanced Kidney Disease Who Forgo Maintenance Dialysis: A Systematic Review

IMPORTANCE

An understanding of the long-term outcomes of patients with advanced chronic kidney disease not treated with maintenance dialysis is needed to improve shared decision-making and care practices for this population.

OBJECTIVE

To evaluate survival, use of health care resources, changes in quality of life, and end-of-life care of patients with advanced kidney disease who forgo dialysis.

EVIDENCE REVIEW

MEDLINE, Embase (Excerpta Medica Database), and CINAHL (Cumulative Index of Nursing and Allied Health Literature) were searched from inception through December 3, 2021, for all English language longitudinal studies of adults in whom there was an explicit decision not to pursue maintenance dialysis. Two investigators independently reviewed all studies and selected those reporting survival, use of health care resources, changes in quality of life, or end-of-life care during follow-up. Studies of patients who initiated and then discontinued maintenance dialysis and patients in whom it was not clear that there was an explicit decision to forgo dialysis were excluded. One author abstracted all study data, of which 12% was independently adjudicated by a second author (<1% error rate).

FINDINGS

Forty-one cohort studies comprising 5102 patients (range, 11-812 patients) were included in this systematic review (5%-99% men; mean age range, 60-87 years). Substantial heterogeneity in study designs and measures used to report outcomes limited comparability across studies. Median survival of cohorts ranged from 1 to 41 months as measured from a baseline mean estimated glomerular filtration rate ranging from 7 to 19 mL/min/1.73 m2. Patients generally experienced 1 to 2 hospital admissions, 6 to 16 in-hospital days, 7 to 8 clinic visits, and 2 emergency department visits per person-year. During an observation period of 8 to 24 months, mental well-being improved, and physical well-being and overall quality of life were largely stable until late in the illness course. Among patients who died during follow-up, 20% to 76% had enrolled in hospice, 27% to 68% died in a hospital setting and 12% to 71% died at home; 57% to 76% were hospitalized, and 4% to 47% received an invasive procedure during the final month of life.

CONCLUSIONS AND RELEVANCE

Many patients who do not pursue dialysis survived several years and experienced sustained quality of life until late in the illness course. Nonetheless, use of acute care services was common and intensity of end-of-life care highly variable across cohorts. These findings suggest that consistent approaches to the study of conservative kidney management are needed to enhance the generalizability of findings and develop models of care that optimize outcomes among conservatively managed patients.

Sexuality in Kidney Transplant Recipients: A Qualitative Study

End-stage kidney disease has a negative impact on patients’ quality of life. People who receive a kidney transplant experience an improvement in many areas of their daily life. Sexuality is a general component of health, which can be affected by end-stage kidney disease and kidney transplant. The aim of this study was to explore and understand the experiences and perspectives of kidney transplant recipients regarding their sexuality. A qualitative study based on Gadamer’s hermeneutic philosophy was carried out. Two focus groups and nine interviews were conducted with 18 kidney transplant recipients. Data were audio-recorded, transcribed, and analyzed with the help of qualitative analysis software. Two main themes emerged from the data: (1) “The impact of a kidney transplant on sexuality”, with the subthemes “sexuality is relegated to the background”, “physical decline acts as a sexual inhibitor”, and “changes in sexual activity following a kidney transplant”; (2) “Sexual education in kidney transplant recipients” with the subthemes “sexuality: a hidden concern amongst kidney transplant recipients” and “talking about sexuality with healthcare professionals”. Sexuality is a frequent concern among kidney transplant recipients. The physiological and emotional changes experienced after kidney transplant exert a great influence on their sexuality. Healthcare professionals rarely discuss sexuality concerns with kidney transplant recipients. Professional sexual education and assistance are necessary to improve sexual health satisfaction of kidney transplant recipients.

Shared decision making for the initiation and continuation of dialysis: a proposal from the Japanese Society for Dialysis Therapy

Background

In Japan, forgoing life-sustaining treatment to respect the will of patients at the terminal stage is not stipulated by law. According to the Guidelines for the Decision-Making Process in Terminal-Stage Healthcare published by the Ministry of Health, Labor and Welfare in 2007, the Japanese Society for Dialysis Therapy (JSDT) developed a proposal that was limited to patients at the terminal stage and did not explicitly cover patients with dementia. This proposal for the shared decision-making process regarding the initiation and continuation of maintenance hemodialysis was published in 2014.

Methods and results

In response to changes in social conditions, the JSDT revised the proposal in 2020 to provide guidance for the process by which the healthcare team can provide the best healthcare management and care with respect to the patient's will through advance care planning and shared decision making. For all patients with end-stage kidney disease, including those at the nonterminal stage and those with dementia, the decision-making process includes conservative kidney management.

Conclusions

The proposal is based on consensus rather than evidence-based clinical practice guidelines. The healthcare team is therefore not guaranteed to be legally exempt if the patient dies after the policies in the proposal are implemented and must respond appropriately at the discretion of each institution.

Communication principles and practices for making shared decisions about renal replacement therapy: a review of the literature

PURPOSE OF REVIEW

To provide an overview of the skill set required for communication and person-centered decision making for renal replacement therapy (RRT) choices, especially conservative kidney management (CKM).

RECENT FINDINGS

Research on communication and decision-making skills for shared RRT decision making is still in infancy. We adapt literature from other fields such as primary care and oncology for effective RRT decision making.

SUMMARY

We review seven key skills: (1) Announcing the need for decision making (2) Agenda Setting (3) Educating patients about RRT options (4) Discussing prognoses (5) Eliciting patient preferences (6) Responding to emotions and showing empathy, and (7) Investing in the end. We also provide example sentences to frame the conversations around RRT choices including CKM.

Musculoskeletal Disorders and Associated Factors Among Patients with Chronic Kidney Disease Attending at Saint Paul Hospital, Addis Ababa, Ethiopia

Background

Musculoskeletal disorders contributed from chronic kidney disease are increasing worldwide. Musculoskeletal disorders had a significant health burden and are leading causes of co-morbidities, disability and low productivity, which potentially affect individual's functional status and quality of life.

Purpose

The aim of this study was to assess the prevalence of musculoskeletal disorders and its associated factors among patients with chronic kidney attending in Saint Paul Hospital, Addis Ababa, Ethiopia.

Patients and Methods

An institution-based cross-sectional study was conducted on 302 enrolled study participants through systematic random sampling techniques. Face-to-face interview, physical examination and chart reviews were used to collect data using semi-structured questionnaire adapted from a standard Nordic Musculoskeletal Questionnaire and other literatures. Data were entered into Epi Info version 7 and exported to SPSS version 23 for analysis. Bivariate logistic regression analysis was employed with a p-value less than 0.25. Finally, those variables having a p-value less than 0.05 with 95% CI in multivariate analysis were taken as statistically significant.

Results

The prevalence of musculoskeletal disorders among CKD individuals was found to be 58.6% (95% CI; 53.0, 64.1). Being female (AOR = 0.49; 95% CI 0.26, 0.94), age between 40 and 49 (AOR = 3.34; 95% CI 1.07, 10.44), stage III (AOR = 0.24; 95% CI 0.06, 0.89) and stage IV (AOR = 0.24; 95% CI 0.06, 0.89) chronic kidney disease, having HTN (AOR = 7.47; 95% CI 3.47, 16.06), parathyroid hormone level ≥100 pg/mL (AOR = 0.43; 95% CI 0.21, 0.87), calcium level <8.4 mg/dl (AOR = 5.89; 95% CI 2.66, 13.56) and serum 25 hydroxy vitamin D level <20 ng/mL (AOR = 3.91; 95% CI 1.32, 11.56) were significantly associated with musculoskeletal disorders.

Conclusion

MSDs were shown to be moderately common in CKD patients. Female gender, age between 40 and 49 yrs, stage III and stage IV CKD, hypertension, higher PTH level, lower calcium level and lower vitamin D level were statistically significant in their association with musculoskeletal disorders.

Terms of specialized nursing language for chronic renal patients undergoing conservative treatment

OBJECTIVES

to validate the terms of the specialized nursing language used in the care of people with chronic kidney disease undergoing conservative treatment identified in the literature by mapping them with terms of the International Classification for Nursing Practice, version 2019, and representing them by means of a mandala.

METHODS

descriptive, documentary and methodological study. The terms were collected in 53 scientific articles, standardized and mapped with the terminology. The validation was performed by six nurses through a focus group. The Content Validity Index was used and terms with a value ≥ 0.80 were validated.

RESULTS

the normalization resulted in 957 relevant terms, of which 499 were constant and 458 not included in the terminology. Terms were validated when Content Validity Index was between 0.86 and 1.0.

CONCLUSIONS

the study allowed the validation of terms that will contribute to unify the professional language of nursing in the care of people with chronic kidney disease.

Biocompatibility performance evaluation of high flux hydrophilic CO3Ap/HAP/PSF composite membranes for hemodialysis application

Carbonate apatite/hydroxyapatite (CO3Ap/HAP) additive was obtained by calcination of wasted chicken bones at 900°C. Intermolecular attraction exists between CO3Ap/HAP additive and blended polysulfone (PSF) polymer. Electron dispersive X-ray (EDX) and FTIR analysis were carried out to check the elemental composition and bonding chemistry of prepared additive. The instantaneous demixing process generated consistent finger-like networks in CO3Ap/HAP/PSF-based composite membranes while sponge-like structure was shown by PSF as revealed by SEM images. The increase in weight % of additive loading is also confirmed by EDX analysis. Furthermore, the interaction mechanism of CO3Ap/HAP additive with polysulfone medium was analyzed by FTIR exploration. The water absorption experiment defined a 93% expansion in hydrophilic performance. Change in porosity occurs with additive loading and pure water permeation flux improved up to 11 times. Approximately, antifouling results revealed that 87% of water flux was recovered after treating with a protein solution, whereas a 30% improvement in antifouling capability in case of bovine serum albumin solution occurred. In vitro cytotoxicity, and clotting times study was carried out to evaluate virulent behavior and anticoagulation activity of formulated membranes.

Correlation of sociodemographic profiles with psychological problems among hospitalized patients receiving unplanned hemodialysis

Purpose

In this prospective study, we aimed to examine the sociodemographic factors and clinical factors associated with psychological disorders in chronic kidney disease (CKD) patients receiving unplanned hemodialysis (HD).

Methods

We prospectively enrolled 187 CKD stage 5 patients receiving unplanned HD at a tertiary hospital from January 2015 to December 2016. We used structured questionnaires to gather data about participants’ anxiety, depression, and sleep disturbance. Generalized linear regression analysis was used to examine the relationships between sociodemographic and laboratory parameters, and severity of psychological distress.

Results

The mean age of the participants was 60 years, and the number of men and women was 97 and 90, respectively. We did not find a significant association between anxiety, depression, and sleep disturbance scores and gender, age, marital status, religion status, education levels, and employment status and number of comorbidities. Generalized linear regression analysis showed that a multidisciplinary CKD care program in outpatient clinic disclosed a significant negative association with psychological disorders in participants.

Conclusions

CKD patients exhibited psychological distress when receiving unplanned HD, not closely associated with sociodemographic profiles.

Health-related quality of life in patients with chronic kidney disease

Introduction: In the last three decades, health systems have continued to pay increasing attention to the quality of life (QOL) due to definitional changes in the concept of health and disease. The health-related quality of life (HRQOL) in patients with chronic kidney disease (CKD) is significantly affected, regardless of the stage of CKD. Areas covered: We attempt to thoroughly explore how CKD affects HRQOL domains with a quick primer on HRQOL assessment instruments in patients with CKD. Also, we pointed out the factors affecting HRQOL in patients with CKD as well as the clinical application of HRQOL in CKD management. Expert opinion: The general population enjoys higher HRQOL than patients with CKD in all domains. Similarly, pre-dialysis and kidney-transplant patients have better HRQOL than dialysis population. There are many factors which negatively impact HRQOL in CKD which include for example depression, anxiety, and cognitive impairment for the social domain, inactivity, and frailty for the physical domain as well as lack of social support and extroversion in the social domain. Additionally, social disparities and CKD-related factors would influence HRQOL. Of note, there is no global standard HRQOL assessment tool. Finally, HRQOL should be included in future CKD management guidelines.

The Prepare for Kidney Care Study: prepare for renal dialysis versus responsive management in advanced chronic kidney disease

Shared decision making in advanced chronic kidney disease (CKD) requires unbiased information on survival and person-centred outcomes known to matter to patients: quality of life, symptom burden and support from family and healthcare professionals. To date, when deciding between dialysis and conservative care, patients have had to rely on evidence from small observational studies. Clinicians recognize that like is not being compared with like in these studies, and interpret the results differently. Furthermore, support differs considerably between renal units. What patients choose therefore depends on which renal unit they attend. To address this, a programme of work has been underway in the UK. After reports on survival and symptoms from a small number of renal units, a national, mixed-methods study-the Conservative Kidney Management Assessment of Practice Patterns Study-mapped out conservative care practices and attitudes in the UK. This led to the Prepare for Kidney Care study, a randomized controlled trial comparing preparation for dialysis versus preparation for conservative care. Although powered to detect a positivist 0.345 difference in quality-adjusted life years between the two treatments, this trial also takes a realist approach with a range of person-centred secondary outcomes and embedded qualitative research. To understand generalizability, it is nested in an observational cohort study, which is nested in a CKD registry. Challenges to recruitment and retention have been rapidly identified and addressed using an established embedded mixed methods approach-the QuinteT recruitment intervention. This review considers the background to and progress with recruitment to the trial.

Health-related quality of life and symptoms of conservative care versus dialysis in patients with end-stage kidney disease: a systematic review

Background

Non-dialytic conservative care (CC) has been proposed as a viable alternative to maintenance dialysis for selected older patients to treat end-stage kidney disease (ESKD). This systematic review compares both treatment pathways on health-related quality of life (HRQoL) and symptoms, which are major outcomes for patients and clinicians when deciding on preferred treatment.

Methods

We searched PubMed, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus and PsycINFO from inception to 1 October 2019 for studies comparing patient-reported HRQoL outcomes or symptoms between patients who chose either CC or dialysis for ESKD.

Results

Eleven observational cohort studies were identified comprising 1718 patients overall. There were no randomized controlled trials. Studies were susceptible to selection bias and confounding. In most studies, patients who chose CC were older and had more comorbidities and worse functional status than patients who chose dialysis. Results were broadly consistent across studies, despite considerable clinical and methodological heterogeneity. Patient-reported physical health outcomes and symptoms appeared to be worse in patients who chose CC compared with patients who chose dialysis but had not yet started, but similar compared with patients on dialysis. Mental health outcomes were similar between patients who chose CC or dialysis, including before and after dialysis start. In patients who chose dialysis, the burden of kidney disease and impact on daily life increased after dialysis start.

Conclusions

The available data, while heterogeneous, suggest that in selected older patients, CC has the potential to achieve similar HRQoL and symptoms compared with a dialysis pathway. High-quality prospective studies are needed to confirm these provisional findings.