Shared Decision Making for Choosing renAl Replacement Therapy in Chronic Kidney Disease Patients (SDM-ART trial): study protocol for randomized clinical trial

BACKGROUND

Patients with chronic kidney disease (CKD) should be educated about their condition so that they can initiate dialysis at the optimal time and make an informed choice between dialysis modalities. Shared decision-making (SDM) empowers patients to select their own treatment and improves patient outcomes. This study aimed to evaluate whether SDM affects the choice of renal replacement therapy among CKD patients.

METHODS

This is a multicenter, open-label, randomized, pragmatic clinical trial. A total of 1,194 participants with CKD who are considering renal replacement therapy were enrolled. The participants will be randomized into three groups in a 1:1:1 ratio: the conventional group, extensive informed decision-making group, and SDM group. Participants will be educated twice at months 0 and 2. Videos and leaflets will be provided to all patients. Patients in the conventional group will receive 5 minutes of education at each visit. The extensive informed decision-making group will receive more informed and detailed education using intensive learning materials for 10 minutes each visit. Patients in the SDM group will be educated for 10 minutes each visit according to illness perception and item-based analysis. The primary endpoint is the ratio of hemodialysis to peritoneal dialysis and kidney transplantation among the groups. Secondary outcomes include unplanned dialysis, economic efficiency, patient satisfaction, patient evaluation of the process, and patient adherence.

DISCUSSION

The SDM-ART is an ongoing clinical study to investigate the effect of SDM on the choice of renal replacement therapy in patients with CKD.

Illness perception and treatment adherence in haemodialysis: a systematic review

Patients with kidney failure need lifelong renal replacement therapy to survive and, worldwide, in-centre haemodialysis is the most common modality. The efficacy of this treatment largely depends on the patients' adherence to several health behaviours. According to Leventhal's self-regulation model, patients' illness perceptions can be a key factor for treatment adherence. Therefore, it is of utmost importance to better understand this relationship to further fine-tune the effectiveness of renal rehabilitation programs. This study aimed to systematically review the literature on the association between illness perceptions and treatment adherence in adults undergoing in-centre haemodialysis. The search was performed on PubMed, Scopus, CINAHL, Web of Science (all databases included), and ProQuest (all databases included), from the 17th to the 21st of December 2020. The last update was performed on the 9th of June of 2022. Articles were critically appraised using the Joanna Briggs Institute (JBI) Critical Appraisal Checklists for Analytical Cross-Sectional Studies. Nine studies were included comprising a total of 1161 patients undergoing in-centre haemodialysis. Associations between illness perceptions and treatment adherence were found in six studies. Adherence to dietary restrictions was the type of adherence with more significant associations with illness perceptions, followed by fluid control and medication intake. Two studies combining several types of adherences into an overall score also showed significant associations with illness perceptions. No significant associations were found between illness perceptions and adherence to dialysis sessions. These findings suggest that illness perceptions in patients undergoing in-centre haemodialysis should continue to receive research attention. Future interventions should acknowledge the importance of modifying maladaptive illness perceptions to improve treatment adherence in kidney failure. The protocol for this systematic review was registered on PROSPERO (CRD42021231929).

Impact of chronic kidney disease on illness perceptions, coping, self-efficacy, psychological distress and quality of life

Chronic kidney disease (CKD) negatively impacts psychological well-being and quality of life (QoL). Underpinned by the Common Sense Model (CSM), this study evaluated the potential mediating role of self-efficacy, coping styles and psychological distress on the relationship between illness perceptions and QoL in patients living with CKD. Participants were 147 people with stage 3-5 kidney disease. Measures included eGFR, illness perceptions, coping styles, psychological distress, self-efficacy and QoL. Correlational analyses were performed, followed by regression modelling. Poorer QoL was associated with greater distress, engagement in maladaptive coping, poorer illness perceptions and lower self-efficacy. Regression analysis revealed that illness perceptions predicted QoL, with psychological distress acting as a mediator. The proportion of variance explained was 63.8%. These findings suggest that psychological interventions are likely to enhance QoL in CKD, if they target the mediating psychological processes associated with illness perceptions and psychological distress.

Cultural adaptation and psychometric properties of the Patient-weighted Quality of Life in Epilepsy 31 Inventory (QOLIE-31P) in Argentina

OBJECTIVE

This study presents the cultural and linguistic adaptation and psychometric properties of the Argentine version of the Quality of Life in Epilepsy Inventory (QOLIE-31P) scale.

METHODS

An instrumental study was carried out. A version of QOLIE-31P translated into Spanish was provided by the original authors. To assess the content validity, evaluation of expert judges was requested, and the degree of agreement was determined. The instrument was administered to 212 people with epilepsy (PWE) of Argentina, together with the BDI-II, B-IPQ and a sociodemographic questionnaire. A descriptive analysis of the sample was carried out. Discriminative capacity of the items was performed. Cronbach's alpha was calculated to assess reliability. To study the dimensional structure of the instrument, a confirmatory factorial analysis (CFA) was performed. Convergent and discriminant validity was tested through mean difference tests, linear correlation, and regression analysis.

RESULTS

Aiken's V coefficients ranged between .90 and 1 (acceptable), which allows to state that a conceptually and linguistically equivalent version of the QOLIE-31P was reached. Cronbach's Alpha of 0.94 was obtained for the Total Scale (optimal). As a result of CFA, 7 factors were obtained, being the dimensional structure similar to the original version. Also, unemployed PWE reported significant lower scores than employed PWE. Finally, QOLIE-31P scores negatively correlated with depression symptom severity and negative illness perception.

CONCLUSION

The Argentine version of the QOLIE-31P is a valid and reliable instrument, presenting good psychometric properties, such as high internal consistency and a dimensional structure similar to that of the original version.

Investigation of Anxiety and Health Locus of Control in Patients Undergoing Hemodialysis

INTRODUCTION

Hemodialysis is the most frequent treatment modality for End-Stage Renal Disease (ESRD). However, a number of limitations and modifications accompany this treatment, affecting people's physical and psychological well-being and increasing anxiety symptoms. The aim of this study was to investigate the level of anxiety and health locus of control among dialysis patients.

METHODOLOGY

One hundred and five patients on hemodialysis treatment completed a questionnaire with demographic characteristics, the State-Trait Anxiety Inventory and the Multidisciplinary Health Locus of Control Scale.

RESULTS

Women had significantly higher levels of state anxiety than men (p = 0.019). Similarly, patients with primary school education had significantly higher trait and total anxiety levels than those with technological education (p = 0.002 and p = 0.033, respectively). Widowed patients exhibited significantly higher state, trait, and total anxiety levels than married (p = 0.032, p = 0.012, and p = 0.012, respectively). Participants who did not do any kind of exercise had significantly higher level of state, trait, and total anxiety than those who did (p = 0.011, p = 0.015, and p = 0.006, respectively). Respondents who did not have any self-care skills had significantly higher level of state, trait, and total anxiety than those who had (p = 0.011, p = 0.015, and p = 0.006, respectively). State, trait, and total anxiety levels were significantly (p ≤ 0.05) correlated negatively with internal locus of control and positively with "chance" locus of control scale.

CONCLUSIONS

Hemodialysis patients had increased anxiety symptoms and believed that others had control over their health to a greater extent. Renal professionals need to apply effective interventions to dialysis patients in order to help them gain a better sense of control over their health and reduce anxiety symptoms.

Psychological Well-Being of Living Kidney Donors and Recipients

OBJECTIVES

Previous research has indicated that kidney transplantation is associated with longer and better quality of life and can also have psychological impacts to both recipients and living donors. This study aimed to examine the psychological well-being of kidney transplant recipients and living donors in the first Ethiopian kidney transplant program using a psychological well-being framework developed by Ryff.

MATERIALS AND METHODS

All 82 kidney recipients and living donors who underwent medical screening for transplantation or living donation at the St. Paul's Hospital Millennium Medical Transplant Center between the establishment of the Center (September 2015)and the data collection end date (December 2018) were selected using medical records. Seventyfive recipients and 64 donors participated in the study. This study used a cross-sectional study design. Demographic questionnaires and Ryff's 84-item psychological well-being assessment were used. Collected data were analyzed through frequency, percentages, means, t tests, and analyses of variance.

RESULTS

Approximately 83% of study recipients scored in the upper 3 quartiles for composite psychological well-being scores, and 50% of study donors scored in the middle 2 quartiles for composite psychological well-being scores, with roughly 20% in the highest quartile. We found no significant mean difference between recipient and donor subscales, excluding the Personal Growth Subscale, which showed a significant mean difference between recipients (mean [SD] of 69.01[8.39]) and donors (mean [SD] of 65.89 [8.84]). This study revealed no significant psychological mean differences between kidney recipients and donors regarding the demographic characteristics of sex, age, marital status, and education.

CONCLUSIONS

Our single-center study cohort of kidney transplant recipients and living donors revealed overall psychological well-being scores similar to established transplant centers in other countries. Psychological well-being subscore data can provide meaningful information about the experiences of recipients and donors.

Psychological factors associated with self-management in multiple sclerosis

OBJECTIVE

Patient's engagement in their own treatment has been shown to improve clinical outcomes. A better understanding of the association between self-management in multiple sclerosis (MS) and potentially modifiable psychological factors may provide clinicians with strategies to design and stimulate better patient activation for self-managing health. Therefore, in this study, we examined whether cognitive factors, namely self-efficacy, acceptance of illness, optimism, and health locus of control (HLC), are associated with self-management in MS.

METHODS

This is a cross-sectional study. A total of 382 patients with MS who completed the MS Self-Management Scale-Revised and the questionnaires that measure self-efficacy, optimism, illness acceptance, and HLC were included in the study.

RESULTS

A hierarchical multiple regression revealed that power of others' HLC (b = 0.42, P ≤ .001), optimism (b = 0.27, P ≤ .01), internal HLC (b = -0.11, P = .017), and self-efficacy (b = 0.11, P = .031), together with control variables (longer disease duration and higher disability), explained 30% of the variance in the dependent variable.

CONCLUSIONS

In the case of MS, self-management is associated with patient's perception that healthcare professionals control their health, higher self-efficacy, optimism, and, surprisingly, lower internal HLC. The results of this study indicate the vital role of the healthcare staff in encouraging the patients with MS toward activities related to self-management and provide new insights on the psychological intervention aimed at improving self-management by patients.

Self-management and associated factors among patients with end-stage renal disease undergoing hemodialysis at health facilities in Addis Ababa, Ethiopia

INTRODUCTION

Patients with end-stage renal disease (ESRD) face multifaceted problems arising from complications of the disease and dialysis that require consistent and, effective self-management from the patients' side, on top of the management offered by health care professionals. However, little is known about the level of self-management and influencing factors among patients with ESRD undergoing hemodialysis in the study area. Therefore, the aim of this study was to assess self-management and associated factors of patients with ESRD undergoing hemodialysis at health facilities in Addis Ababa, Ethiopia.

METHODS

An institution-based cross-sectional survey was used to recruit 169 patients with ESRD undergoing hemodialysis from six private health facilities between March and April 2016. Data were collected using an interviewer-administered structured questionnaire inquiring about patients' self-management and associated factors. Data were entered into EpiData Version 3.1 and analyzed using the descriptive, correlation, and logistic regression using the SPSS Version 22.0 statistical software.

RESULTS

The mean age of the patients was 49.86±15.58 years. The majority of the respondents (69.8%) were male, and 65.7% of them were married. Half of the respondents (50.3%) had diploma and above educational level. The great majority of the respondents (93.5%) were on hemodialysis for less than 5 years, and 53.3% of them underwent dialysis twice a week. More than half (57.4%) of the patients had low levels of self-management. There were statistically significant positive associations between self-management and education (adjusted OR [AOR] =6.25, 95% CI =1.40, 27.85), knowledge (AOR =5.5, 95% CI =2.15, 14.03), and self-efficacy (AOR =4.73, 95% CI =1.95, 11.48), while there were statistically significant negative associations between self-management and anxiety (AOR =3.19, 95% CI =1.28, 7.95) and depression (AOR =2.68, 95% CI =1.01, 7.05, P<0.05).

CONCLUSION

Patients' education, knowledge, self-efficacy, anxiety, and depression were found to be independent predictors of self-management.

Exploring the relationship between illness perceptions and depression in patients with chronic kidney disease: A systematic literature review

BACKGROUND

The prevalence of depression is found to increase from early stages to later stages of chronic kidney disease. Research on illness perceptions in patients undergoing dialysis has confirmed that patients' beliefs are associated with important outcomes; one of the most significant being depression. However, the association between illness perceptions and depression in patients in pre-dialysis care remains unclear.

OBJECTIVE

The main objective of this systematic review was to explore the associative relationship between illness perceptions and depression in patients with CKD prior to the commencement of dialysis.

METHODS

The inclusion criteria for papers in this review were studies investigating illness perceptions and depression in patients diagnosed with CKD. Eligible studies were identified by searching the following electronic databases; Medline, CENTRAL, Embase, Psych INFO, Web of Science and Scopus. Data on the participants and the severity of kidney disease, illness perceptions and depression were extracted.

RESULTS

Sixty-four studies met the criteria for full text review and of these, only four studies met the inclusion criteria following data extraction and quality assessment. Consistent with the common sense model, disease severity was found to be significantly associated with illness perceptions, and both were found to be associated with depression CONCLUSIONS: The results from this review provide further evidence that the illness perceptions and disease severity play a crucial role in the adaption to CKD. This review highlights the lack of research in this area and concludes that more studies are needed to determine the nature and impact of illness perceptions in relation to depression in pre-dialysis CKD.

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

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

Screening for psychological distress using the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS): Initial validation of structural validity in dialysis patients

OBJECTIVE

To validate the factor structure of the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS)- which is a composite measure of depression and anxiety using the Patient Health Questionnaire-9 and Generalised Anxiety Disorder Scale (GAD-7), in a sample of haemodialysis patients.

METHOD

Screening data (n=182) used to select entry into a feasibility study of an online cognitive-behavioural therapy intervention for distress in dialysis patients were analysed here. Structural validity of the PHQ-ADS was evaluated using confirmatory factor analysis (CFA), assessing alternative models including a bi-factor model. In the bi-factor model all items from the PHQ-9 and GAD-7 (16-items in total) were loaded onto a general distress factor. Respective items of the PHQ-9 and GAD-7 were specified as subgroup factors. Omega-hierarchical was calculated to indicate the level of saturation of a multidimensional scale by a general factor. Construct validity was determined against the Brief Illness Perception Questionnaire.

RESULTS

A bi-factor PHQ-ADS model had good fit to the data (chi-square=96.1, p=0.26, CFI=0.99; TLI=0.99; RMSEA=0.02). The general distress factor accounted for approximately 84% of the explained variance (omega-h=0.90). Distress scores were significantly higher in females compare with males. There was a significant association between distress and negative illness perceptions (r=0.58, p<0.01).

CONCLUSIONS

The PHQ-ADS appears to have good structural validity in haemodialysis patients and is sufficiently unidimensional to warrant the use of a total distress score. A full psychometric analysis of the PHQ-ADS in a larger sample of dialysis patients is warranted.

Body-image, quality of life and psychological distress: a comparison between kidney transplant patients and a matching healthy sample

The purpose of the current study was to assess the uniqueness of the condition of kidney transplant recipients in comparison to a sample of matching healthy peers in relation to body-image dissatisfaction and identification, quality of life and psychological distress. Participants were 45 kidney transplant recipients who were under follow-up care at a Transplant Unit of a major Medical Center, and a sample of 45 matching healthy peers. Measures were taken using self-report questionnaires [Body-Image Ideals Questionnaire (BIIQ), Body Identification Questionnaire (BIQ), Brief Symptoms Inventory (BSI), and the SF-12]. The major findings were the following: (i) kidney transplant recipients reported lower levels of quality of life and higher levels of PsD when compared to their healthy peers; (ii) no difference in body-image dissatisfaction was found between the two studied groups; (iii) significant correlations between body-image dissatisfaction quality of life and PsD were found only in the kidney transplant recipients. The kidney transplantation condition has a moderating effect in the association between body-image dissatisfaction PsD but not in the association between body-image dissatisfaction and quality of life; (iv) kidney transplant recipients experienced higher levels of body identification than did their healthy peers. Taken together, these findings highlight the unique condition of kidney transplant recipients, as well as the function that body-image plays within the self.

Exploring the nature of illness perceptions in people with end-stage kidney disease

BACKGROUND

Diagnosis and treatment for End-Stage Kidney Disease (ESKD) results in vast lifestyle changes. Despite the high prevalence of depression in people with ESKD, the psychosocial impacts of ESKD are still often overlooked. Illness perceptions enable people to make sense of their illness and are closely associated with depression. Due to the high levels of depression within ESKD, this study sought to understand the nature of illness perceptions in people with ESKD.

METHODOLOGY

In this qualitative study, eleven participants were identified through hospital and online patient support groups. Semi-structured interviews were audio-taped, transcribed and analysed using grounded theory techniques.

RESULTS

Three themes emerged from the data: Renal Conflicts, Forced Adjustment and Coping. The main dimensions of illness perception discussed by participants were Consequences, Control, Timeline and Identity.

CONCLUSION

The results of this study have practical implications for informing practitioners about the psychosocial effects of ESKD diagnosis and treatment.

Changes of perceived control after kidney transplantation: a prospective study

AIMS

The aim of this study was to determine if kidney transplantation is associated with increases of perceived control and how changes of perceived control affect the course of psychological distress until 1 year after transplantation.

BACKGROUND

Low levels of perceived control are associated with reduced well-being among dialysis patients.

DESIGN

Prospective longitudinal cohort study.

METHODS

Perceived control (Mastery Scale) and psychological distress (GHQ-12) were prospectively assessed before (T0; n = 470) and three (T1; n = 197), six (T2; n = 210) and twelve (T3; n = 183) months after transplantation. Differences between T1 and T0 perceived control were used to stratify the sample into three groups (control gain, stable control and control loss). Socio-demographic and clinical variables, including complications, were examined as potential correlates and the course of psychological was distress compared across groups. Data were collected between July 2008 - July 2013.

RESULTS

Perceived control showed a small increase overall, with 35·1%, 50·0% and 14·9% reporting gain, stable level and loss respectively. Patients with secondary schooling were overrepresented in the control loss group. The course of psychological distress varied across perceived control change groups, with patients in the control gain group experiencing a significant reduction in psychological distress.

CONCLUSION

A considerable number of patients report increased levels of perceived control after transplantation that are associated with a subsequent decrease in psychological distress. Results emphasize the importance of perceived control and could inform interventions to facilitate well-being after kidney transplantation.

Patient Acceptability of the Yorkshire Dialysis Decision Aid (YoDDA) Booklet: A Prospective Non-Randomized Comparison Study Across 6 Predialysis Services

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BACKGROUND

Patients are satisfied with their kidney care but want more support in making dialysis choices. Predialysis leaflets vary across services, with few being sufficient to enable patients' informed decision making. We describe the acceptability of a patient decision aid and feasibility of evaluating its effectiveness within usual predialysis practice. ♦

METHODS

Prospective non-randomized comparison design, Usual Care or Usual Care Plus Yorkshire Dialysis Decision Aid Booklet (+YoDDA), in 6 referral centers (Yorkshire-Humber, UK) for patients with sustained deterioration of kidney function. Consenting (C) patients completed questionnaires after predialysis consultation (T1), and 6 weeks later (T2). Measures assessed YoDDA's utility to support patients' decisions and integration within usual care. ♦

RESULTS

Usual Care (n = 105) and +YoDDA (n = 84) participant characteristics were similar: male (62%), white (94%), age (mean = 62.6; standard deviation [SD] 14.4), kidney disease severity (glomerular filtration rate [eGFR] mean = 14.7; SD 3.7); decisional conflict was < 25; choice-preference for home versus hospital dialysis approximately 50:50. Patients valued receiving YoDDA, reading it on their own (96%), and sharing it with family (72%). The +YoDDA participants had higher scores for understanding kidney disease, reasoning about options, feeling in control, sharing their decision with family. Study engagement varied by center (estimated range 14 - 49%; mean 45%); participants varied in completion of decision quality measures. ♦

CONCLUSIONS

Receiving YoDDA as part of predialysis education was valued and useful to patients with worsening kidney disease. Integrating YoDDA actively within predialysis programs will meet clinical guidelines and patient need to support dialysis decision making in the context of patients' lifestyle.

Illness Perceptions in Patients on Predialysis Care: Associations With Time Until Start of Dialysis and Decline of Kidney Function

OBJECTIVES

Illness perceptions in patients with end-stage renal disease are associated with nonadherence and increased mortality. However, no data are available regarding the relationship between illness perceptions and accelerated disease progression in predialysis patients.

METHODS

A total of 416 incident predialysis patients participating in a prospective cohort (PREPARE-2, Predialysis Patient Record-2) completed the Revised Illness Perception Questionnaire at the start of specialized predialysis care. The association between illness perceptions and time until start of dialysis was investigated using Cox regression models. Linear mixed modeling was used to test associations between illness perceptions and change of kidney function during predialysis care. Adjustments were made for sociodemographic, clinical, and biochemical factors.

RESULTS

Five illness perceptions were associated with disease progression. Dialysis started earlier and kidney function declined faster (ml/min per 1.73 m/y) in patients who perceived their kidney disease as being cyclical in nature (adjusted hazard ratio [HRadj] = 1.32 [95% confidence interval {CI} = 1.11-1.56]; adjusted additional change = -0.64 [95% CI = -1.16 to -0.13]), having many negative consequences (HRadj = 1.47 [95% CI = 1.18-1.85]; adjusted additional change = -0.67 [-1.30 to -0.04]) and causing negative feelings (HRadj = 1.21 [95% CI = 1.03-1.42]; adjusted additional change = -0.65 [95% CI = -1.13 to -0.16]). In addition, kidney function declined faster in patients who perceived that their kidney disease cannot be personally controlled (adjusted additional change = -0.69 [95% CI = -1.31 to -0.09]) and who perceived that they did not fully understand their kidney disease (adjusted additional change = -0.53 [-1.05 to -0.01]).

CONCLUSIONS

Stronger negative perceptions of illness at the start of predialysis care are a marker for accelerated disease progression. Detecting illness perceptions in predialysis patients may provide opportunities to intervene and slow down disease progression.

Denial Defense Mechanism in Dialyzed Patients

BACKGROUND

It is a struggle to identify the most adaptive coping strategies with disease-mediated stress. Here, we hypothesize that intensity of coping strategies, including denial, in patients with end-stage renal disease (ESRD), varies with type of renal replacement therapy (RRT).

MATERIAL AND METHODS

We enrolled 60 in-center hemodialyzed patients (HD) and 55 patients treated with continuous ambulatory peritoneal dialysis (CAPD). We administered the Coping Inventory with Stressful Situation, Profile of Mood States, and Stroop Anxiety Inventory to measure patient coping strategies in the context of their ESRD. Denial defense mechanism was measured via the IBS-R/ED. The Nottingham Health Profile was used to evaluate self-perceived quality of life. Serum potassium, urea, creatinine, phosphorus, calcium, albumin, and hematocrit were utilized as the measurements of adequacy of dialysis.

RESULTS

HD patients had higher self-reported intensity of denial mechanism and avoidance-oriented strategies versus CAPD patients. Because a single strategy is almost never employed, we conducted cluster analysis. We identify 3 patterns of coping strategies using cluster analysis. "Repressors" employed denial and avoidance strategies and were predominant in HD. The second cluster consists of subjects employing predominantly task-oriented strategies with equal distribution among dialyzed patients. The third cluster encompassed a small group of patients who shared higher intensity of both denial and task-oriented strategies. Health-related outcome, anxiety, and mood profile were similar across all patients.

CONCLUSIONS

HD patients predominantly used "repressive" strategies. Patients on RRT utilized denial and avoidance-based strategies to achieve satisfactory outcome in terms of perceived quality of life. We conclude that these coping mechanisms that were previously thought to be inferior are beneficial to patient compliance with RRT.

Lived experiences and illness representation of Taiwanese patients with late-stage chronic kidney disease

This qualitative study was designed to identify patients' experiences and perceptions related to living with late-stage chronic kidney disease. Interviews were held for 15 patients with late-stage chronic kidney disease from two medical centers in Taiwan. Five themes were identified using content analysis: experiencing moderate to severe symptoms and signs; tracing back to causes; realizing the long-term, irreversible nature of the disease; facing the consequence of unavoidable deterioration; and coping with the disease. The findings present the special lived experiences of Taiwanese chronic kidney disease patients and highlight the need for healthcare providers to assess patients' illness representation before offering interventions for patients coping with chronic kidney disease.

Psychosocial distress in patients with end-stage kidney disease

This is the first paper in a two-part Continuing Education (CE) series focusing on psychosocial care of patients with end-stage kidney disease (ESKD), which addresses a variety of psychological responses experienced by patients when adapting to the challenges posed by living with this long-term condition. The second paper will examine further the issues of coping and adjustment to ESKD and the need for renal supportive care to ensure person-centred holistic care is provided to patients.

DIFFERENCES IN ILLNESS REPRESENTATIONS IN PATIENTS WITH CHRONIC KIDNEY DISEASE

OBJECTIVE

To explore the impact of chronic kidney disease (CKD) on individual illness representations, including symptoms and causal attributions.

DESIGN AND MEASURES

Fifty-four patients responded to the Illness Perception Questionnaire (IPQ-R) and a further seven patients undertook cognitive interviews regarding the IPQ-R. All respondents had CKD stage 2-5, not undergoing renal replacement therapy.

RESULTS

Those in earlier CKD stages and those with fewer symptoms perceived a significantly different understanding of their condition than those in more advanced disease stages or with more symptoms. Behavioural and psychological attributions were commonly referred to as contributing causes to CKD. These attributions were associated to negative illness representations. An uncertainty assessing symptoms attributed to CKD was indicated, especially in earlier disease stages.

CONCLUSION

Illness representations differ with CKD stages and symptom burden. The patients in earlier disease stages or with fewer symptoms did not hold as strong beliefs about their illness as being a threat as those in advanced stages or with more symptoms. Self-blame emerged as a common causal attribution. Patients did not always relate symptoms to CKD, therefore this study identifies a gap in patients' disease knowledge, especially in earlier stages of the condition.

Exploring the relationships between health status, illness perceptions, coping strategies and psychological morbidity in a chronic kidney disease cohort

BACKGROUND

Using the common sense model of illness adjustment, this study aimed to explore the impact of chronic kidney disease (CKD) on individual illness perceptions, coping styles and psychological well-being.

METHODS

Eighty individuals (50 men and 30 women) with an average age of 62.66 years (standard deviation, 11.98) were included in the study. All participants were under the care of the Renal Unit of a metropolitan tertiary referral hospital. Twenty-nine patients (36%) had CKD stage 3b-4, and 51 (64%) had CKD stage 5 (or end stage kidney disease [ESKD]). Disease severity was evaluated using the health perceptions questionnaire, coping styles assessed with the Carver brief COPE scale, illness perceptions explored with the brief illness perceptions questionnaire and anxiety and depression measured using the hospital anxiety and depression scale.

RESULTS

The hospital anxiety and depression scale assessment revealed 13 patients (16.3%) with moderate or severe anxiety and 6 (7.5%) with moderate depression. Consistent with the common sense model, disease activity had a significant direct influence on illness perceptions, while, in turn, illness perceptions had a significant direct influence on depression and anxiety. Adaptive and maladaptive coping were found to mediate the relationship between illness perceptions, and anxiety and depression.

CONCLUSIONS

The results provide evidence that it is the perception of an illness rather than the actual symptoms themselves that best account for adaption to CKD. These findings suggest that intervention strategies aimed at increasing psychological well-being need to focus on changing illness perceptions rather than improving symptoms of CKD or coping mechanisms.

Quality of life in end stage renal disease patients

AIM: To understand factors associated with quality of life (QOL), examine types of QOL instruments, and determine need for further improvements in QOL assessment.

METHODS: The method used databases (Pubmed, Google scholar) and a bibliographic search using key words QOL, end stage renal disease, Hemodialysis, Peritoneal dialysis, instruments to measure QOL, patients and qualitative/quantitative analysis published during 1990 to June 2014. Each article was assessed for sample size, demographics of participants, study design and type of QOL instruments used. We used WHO definition of QOL.

RESULTS: For this review, 109 articles were screened, out of which 65 articles were selected. Out of 65 articles, there were 19 reports/reviews and 12 questionnaire manuals. Of the 34 studies, 82% were quantitative while only 18% were qualitative. QOL instruments measured several phenomenon such as physical/psychological health, effects and burdens of kidney disease, social support etc. those are associated with QOL. Few studies looked at spiritual beliefs, cultural beliefs, personal concerns, as per the WHO definition. Telemedicine and Palliative care have now been successfully used however QOL instruments seldom addressed those in the articles reviewed. Also noticed was that longitudinal studies were rarely conducted. Existing QOL instruments only partially measure QOL. This may limit validity of predictive power of QOL.

CONCLUSION: Culture and disease specific QOL instruments that assess patients’ objective and subjective experiences covering most aspects of QOL are urgently needed.

Does online haemodiafiltration reduce intra-dialytic patient symptoms?

INTRODUCTION

Patients often suffer from symptoms during dialysis. Haemodiafiltration (HDF) therapy has been suggested to be superior to standard haemodialysis (HD). To understand patients' experiences, we quantified the burden and duration of dialysis-associated symptoms to determine whether there was any difference between the modalities.

METHODS

Symptom questionnaires (83.3%) were returned by 623 dialysis outpatients. Symptom scores were analysed using a visual analogue score. We compared symptom burdens during HD and HDF treatments and also whether the scores changed following a modality change to HDF.

RESULTS

Among the patients, 55.7% were men, the median age was 65 years, 39.7% were diabetic, 26.4% were treated by HDF and the median unadjusted Charlson co-morbidity score was 6 (IQR 4-8). Fatigue (77.3%), intra-dialytic hypotension (76.4%), cramps (74.3%) and dizziness (63%) were the commonest symptoms reported, followed by headache (53.6%) and pruritus (52.2%). Although most symptoms were reported less frequently with HDF [median headache frequency score: HD: 1 (IQR 1-4) vs. HDF: 0 (IQR 0-2), p < 0.005]. There was no evidence of a reduction in symptom scores in patients switching from HD to HDF compared to those remaining on HD.

CONCLUSION

Patient self-reporting shows that most patients frequently suffer symptoms. There was no evidence that switching to HDF improved symptoms in patients established on HD.

Factors associated with self-management by people undergoing hemodialysis: a descriptive study

BACKGROUND

Improving the level of self-management by people undergoing hemodialysis is an effective way to reduce the incidence of mortality and complications and improve quality of life. A better understanding of what influences an individual's level of self-management can help nurses find appropriate ways to improve self-management.

OBJECTIVES

To examine self-management levels, and discuss the factors influencing self-management, in a sample of patients undergoing hemodialysis in Beijing.

DESIGN

A descriptive study design was chosen.

SETTINGS AND METHODS

A convenience sample of 216 patients undergoing hemodialysis was recruited from dialysis centers in three tertiary hospitals in Beijing from September 2010 to January 2011. Questionnaires were used to examine the variables: level of self-management; knowledge of hemodialysis; self-efficacy; anxiety and depression; and social support. Data analysis involved descriptive statistics, including frequency, percentage, mean and standard deviations, while Spearman correlation, non-parametric Z and χ(2) and multiple linear regression were used for comparative purposes.

RESULTS

The number of returned questionnaires was 198 (91.67% response rate). The overall score of self-management was 56.01 (SD=10.75). The average item scores for each of the four self-management subscales were 3.02 for partnership, 2.98 for problem-solving skills, 2.74 for self-care and 2.47 for emotional management. Multiple linear regression analyses for overall self-management and the four subscales indicated that knowledge, self-efficacy, the availability of social support and depression were the main influencing factors which explained 34.1% of the variance of self-management.

CONCLUSION

The level of self-management by those undergoing hemodialysis in this study was less than ideal, varying from 'rare' to 'sometimes' for use of self-management behaviors. For the different subscales of self-management, partnership was the most used and emotional management the least used strategy. Patients' knowledge, self-efficacy, the availability of social support and depression were the main factors influencing self-management.

A systematic review of patient-reported measures of burden of treatment in three chronic diseases

Background

Burden of treatment refers to the workload of health care and its impact on patient functioning and well-being. There are a number of patient-reported measures that assess burden of treatment in single diseases or in specific treatment contexts. A review of such measures could help identify content for a general measure of treatment burden that could be used with patients dealing with multiple chronic conditions. We reviewed the content and psychometric properties of patient-reported measures that assess aspects of treatment burden in three chronic diseases, ie, diabetes, chronic kidney disease, and heart failure.

Methods

We searched Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, and EBSCO CINAHL through November 2011. Abstracts were independently reviewed by two people, with disagreements adjudicated by a third person. Retrieved articles were reviewed to confirm relevance, with patient-reported measures scrutinized to determine consistency with the definition of burden of treatment. Descriptive information and psychometric properties were extracted.

Results

A total of 5686 abstracts were identified from the database searches. After abstract review, 359 full-text articles were retrieved, of which 76 met our inclusion criteria. An additional 22 articles were identified from the references of included articles. From the 98 studies, 57 patient-reported measures of treatment burden (full measures or components within measures) were identified. Most were multi-item scales (89%) and assessed treatment burden in diabetes (82%). Only 15 measures were developed using direct patient input and had demonstrable evidence of reliability, scale structure, and multiple forms of validity; six of these demonstrated evidence of sensitivity to change. We identified 12 content domains common across measures and disease types.

Conclusion

Available measures of treatment burden in single diseases can inform derivation of a patient-centered measure of the construct in patients with multiple chronic conditions. Patients should take part in developing the measure to ensure salience and relevance.

Age-related differences in the quality of life in end-stage renal disease in patients enrolled in hemodialysis or continuous peritoneal dialysis

Background

The aim of the present study was to compare the experience elderly and younger patients in terms of emotional status, disease perception, methods of coping with the end-stage renal disease (ESRD) stress, and health-related quality of life in 2 different settings of renal replacement therapy: hemodialysis (HD) and continuous ambulatory peritoneal dialysis programs (CAPD). Specifically, we hypothesized that younger people will more frequently use goal-oriented strategies to cope with illness-related stress and elderly patients will use more strategies related to the control of emotion.

Material/Methods

A total of 69 HD patients, 40 CAPD patients, and 89 healthy volunteers were analyzed. The Situation and Trait Anxiety Inventory, the Profile of Mood States, the Cognitive Stress Appraisal Questionnaire, and the Nottingham Health Profile were used to assess anxiety, long-term emotional status, coping mechanisms, and health-related quality of life. Data were collected on several biochemical and demographic variables.

Results

Our study revealed that younger and elderly people on dialysis faced quite different problems. Younger people in both RRT groups had statistically higher assessment of ESRD as loss or challenge and they more frequently used distractive and emotional preoccupation coping strategies. Depression, confusion, and bewilderment dominate the emotional status of both patient populations, especially in the younger cohort. Both HD_young and CAPD_young patients complained more about lack of energy, mobility limitations, and sleep disturbances as compared to their elderly HD and CAPD counterparts.

Conclusions

There are different needs and problems in younger and elderly patients on renal replacement therapy. Younger people required more ESRD-oriented support to relieve their health-related complaints to the level observed in their peers and needed extensive psychological assistance in order to cope with negative emotions related to their disease.

Self-Reported Functional Status

Functional status is an understudied, yet important, modifiable risk factor in a number of chronic illnesses. This topic has not yet been studied extensively for chronic kidney disease (CKD). This study investigates the relationship of functional status to mental health and health perceptions among patients undergoing hemodialysis and peritoneal dialysis. A sample of 144 patients was recruited, consisting of 84 patients undergoing hemodialysis (HD) and 60 patients in peritoneal dialysis (PD). Measurements were conducted with the following instruments: the World Health Organization Quality of Life instrument (WHOQOL-BREF), the General Health Questionnaire (GHQ-28), the State-Trait Anxiety Inventory (STAI 1/STAI 2), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Multidimensional Health Locus of Control (MHLC). Functional status was associated negatively with all subscales of the GHQ-28 (somatic symptoms, anxiety/insomnia, social dysfunction, severe depression) and the GHQ-28 total score. It was also related negatively to depression, as measured by CES-D scale, as well as to state and trait anxiety, and positively to internal health locus of control. The present study demonstrates the importance of functional status in understanding the health perceptions of patients with CKD and the contribution of functional status to mental health.

The psychosocial experience of patients with end-stage renal disease and its impact on quality of life: findings from a needs assessment to shape a service

Background. A needs assessment was conducted on renal patients registered to a leading hospital trust in London in order to explore their psychological, social, and spiritual needs. The aim of the needs assessment was to create an evidence base for the development of a comprehensive health psychology service to run concurrently with a renal counselling support service within the department. Methodology. This study utilised a series of semistructured face-to-face interviews and focus groups with renal patients and their carers, to explore how ESRD impacted quality of life. Results. A thematic analysis was undertaken. Seven emergent themes were identified that influenced the quality of life of people with EDRD: physiological impact, impact of treatment, impact on daily life, psychological impact, impact on relationships, social impact and coping responses. Conclusion. The needs assessment clearly identified that ESRD carries with it emotional, physical, psychological, social, and existential burdens. The data from this needs assessment study has created an evidence base upon which future health psychology services can be built within this leading UK hospital.

Patient and spouse illness beliefs and quality of life in prostate cancer patients

OBJECTIVE

Among married prostate cancer (PC) patients, the spouse is often the primary provider of emotional support and personal care. However, few studies have investigated spouses' illness beliefs (i.e. about disease duration and treatment control) and their impact on patients' quality of life (QOL). Spouses' beliefs about disease duration (timeline) were hypothesised to mediate relationships between spouses' treatment control beliefs and patients' QOL six months later.

METHODS

Fifty-three patients who underwent localised treatment for PC, and their spouses, completed an illness beliefs measure (the revised Illness Perception Questionnaire). Patients completed a QOL measure (the Functional Assessment of Cancer Therapy - General) six months later.

RESULTS

Spouse timeline beliefs mediated the association between spouse treatment control beliefs and patient QOL six months later (total indirect effect = -0.71, 95% CI 0.02-2.03). That is, spouse beliefs that the treatment would control their loved one's illness led to beliefs that the disease would be of shorter duration, which in turn led to improved patient QOL six months later. This relationship did not occur with patients' beliefs.

CONCLUSION

Results highlight the important influence of spouse illness beliefs over time on patient QOL with implications for clinical care and dyadic research.

Building a measurement framework of burden of treatment in complex patients with chronic conditions: a qualitative study

Background:

Burden of treatment refers to the workload of health care as well as its impact on patient functioning and well-being. We set out to build a conceptual framework of issues descriptive of burden of treatment from the perspective of the complex patient, as a first step in the development of a new patient-reported measure.

Methods:

We conducted semistructured interviews with patients seeking medication therapy management services at a large, academic medical center. All patients had a complex regimen of self-care (including polypharmacy), and were coping with one or more chronic health conditions. We used framework analysis to identify and code themes and subthemes. A conceptual framework of burden of treatment was outlined from emergent themes and subthemes.

Results:

Thirty-two patients (20 female, 12 male, age 26–85 years) were interviewed. Three broad themes of burden of treatment emerged including: the work patients must do to care for their health; problem-focused strategies and tools to facilitate the work of self-care; and factors that exacerbate the burden felt. The latter theme encompasses six subthemes including challenges with taking medication, emotional problems with others, role and activity limitations, financial challenges, confusion about medical information, and health care delivery obstacles.

Conclusion:

We identified several key domains and issues of burden of treatment amenable to future measurement and organized them into a conceptual framework. Further development work on this conceptual framework will inform the derivation of a patient-reported measure of burden of treatment.

The impact of treatment transitions between dialysis and transplantation on illness cognitions and quality of life - a prospective study

OBJECTIVES

Treatment transitions are frequent in end-stage renal disease (ESRD) but little is known about cognitive responses pre- to post-transplantation or after transplant failure. The purpose of this study was to examine changes in illness cognitions across treatment transitions between dialysis and transplantation and their impact on quality of life (QOL).

METHODS

In this longitudinal study, ESRD patients (N= 262) patients were followed up across treatment transitions over a 7-year observation window using the Illness Perceptions Questionnaire, the Illness Effects Questionnaire, and measures of QOL. Study sample comprised the patients from this cohort who switched treatment modality (N= 60 post-transplantation; N= 28 transplant failure). Data were collected while on dialysis or transplantation and at 6 months post-treatment change.

RESULTS

Significant changes in QOL and illness perceptions were found in treatment transitions with opposite patterns of either improvement or deterioration following transplantation or transplantation failure. Pre- to post-transplantation, QOL improves and patients report less symptoms, lower consequences, and illness intrusiveness, more acute timeline and stronger control beliefs (ps < .01). QOL is diminished following transplant failure and patients report more symptoms, consequences, illness disruptiveness, more chronic timeline, and lower control. Changes in cognitions are associated with changes in QOL (R(2) = .469-.789).

CONCLUSIONS

Treatment transitions marked significant changes in illness perceptions that were associated with changes in QOL. Interventions to prepare patients for treatment transitions and prevent increasingly negative patterns of illness perceptions with transplant failure may serve towards maintaining or improving adjustment outcomes.

A questionnaire to evaluate the impact of chronic diseases: validated translation and Illness Effects Questionnaire (IEQ) reliability study

INTRODUCTION: Patients' perception about their health condition, mainly involving chronic diseases, has been investigated in many studies and it has been associated to depression, compliance with the treatment, quality of life and prognosis. The Illness Effects Questionnaire (IEQ) is a tool which makes the standardized evaluation of patients' perception about their illness possible, so that it is brief and accessible to the different clinical settings. This work aims to begin the transcultural adaptation of the IEQ to Brazil through the validated translation and the reliability study. METHODS: The back-translation method and the test-retest reliability study were used in a sample of 30 adult patients under chronic hemodialysis. The reliability indexes were estimated using the Pearson, Spearman, Weighted Kappa and Cronbach's alpha coefficients. RESULTS: The semantic equivalence was reached through the validated translation. In this study, the reliability indexes obtained were respectively: 0.85 and 0.75 (p < 0.001); 0.68 and 0.92 (p < 0.0001). DISCUSSION: The reliability indexes obtained attest to the stability of responses in both evaluations. Additional procedures are necessary for the transcultural adaptation of the IEQ to be complete. CONCLUSION: The results indicate the translation validity and the reliability of the Brazilian version of the IEQ for the sample studied.

Systematic review: kidney transplantation compared with dialysis in clinically relevant outcomes

Individual studies indicate that kidney transplantation is associated with lower mortality and improved quality of life compared with chronic dialysis treatment. We did a systematic review to summarize the benefits of transplantation, aiming to identify characteristics associated with especially large or small relative benefit. Results were not pooled because of expected diversity inherent to observational studies. Risk of bias was assessed using the Downs and Black checklist and items related to time-to-event analysis techniques. MEDLINE and EMBASE were searched up to February 2010. Cohort studies comparing adult chronic dialysis patients with kidney transplantation recipients for clinical outcomes were selected. We identified 110 eligible studies with a total of 1 922 300 participants. Most studies found significantly lower mortality associated with transplantation, and the relative magnitude of the benefit seemed to increase over time (p < 0.001). Most studies also found that the risk of cardiovascular events was significantly reduced among transplant recipients. Quality of life was significantly and substantially better among transplant recipients. Despite increases in the age and comorbidity of contemporary transplant recipients, the relative benefits of transplantation seem to be increasing over time. These findings validate current attempts to increase the number of people worldwide that benefit from kidney transplantation.

Effects of immunosuppressive drugs on the cognitive functioning of renal transplant recipients: a pilot study

Some renal transplant patients show cognitive, emotional, and behavioral changes as part of possible neurotoxic effects associated with immunosuppressive medication, especially tacrolimus. This study evaluated effects of immunosuppressive drugs on some cognitive tasks. Patients treated with sirolimus and cyclosporine reported some of the noncognitive side effects related to immunosuppressive treatment. We observed attention and working memory impairment in patients treated with sirolimus or tacrolimus. Performance of cyclosporine-treated subjects was similar to that of healthy volunteer controls. Since the mood, anxiety, and sleep patterns measured were unaffected, it could be concluded that the cognitive deficit found was partly related to treatment.

Illness representations and concurrent depression symptoms in haemodialysis patients

We examined the association between illness perceptions and depression symptoms in established haemodialysis patients (HD). Two hundred and fifteen patients completed the Revised Illness Perception Questionnaire and the Beck Depression Inventory-II (BDI). Patients with a BDI ≥ 16 were termed as ‘depressed’. Lower personal control and illness coherence, and greater perceived consequences were all related to depression significantly increasing the explained variance over clinical factors. Our findings suggest it is not disease characteristics or co-morbidity per se that is related to mood symptoms in HD patients, rather the apparent interpretation and regulation of the illness.

Maximum conservative management for patients with chronic kidney disease stage 5

Following the expansion of dialysis services for patients with chronic kidney disease, an increasing number of elderly patients with varying degrees of frailty and additional comorbidities have been offered treatment. Life expectancy is somewhat limited in this group of patients, and initiation of dialysis may not necessarily improve quality of life. As such, an increasing number of centers are offering conservative care for patients who have made an informed decision not to have dialysis. As conservative care includes active treatment of anemia, volume overload, blood pressure control, and management of uremic symptoms, including pruritus, we term this approach as maximal conservative management of chronic kidney disease. We describe our experience of maximum conservative management, which although may not prolong life, can maintain the quality of life and functional ability until the final illness in the majority of patients. Although these patients do not go to the hospital on a regular basis, coordinated support from the hospital, the community, and the care giver/relative is required for successful care of the patient. Appropriate end of life planning can then be made according to the wishes of the patient.

The NKF-NUS hemodialysis trial protocol - a randomized controlled trial to determine the effectiveness of a self management intervention for hemodialysis patients

BACKGROUND

Poor adherence to treatment is common in patients on hemodialysis which may increase risk for poor clinical outcomes and mortality. Self management interventions have been shown to be effective in improving compliance in other chronic populations. The aim of this trial is to evaluate the effectiveness of a recently developed group based self management intervention for hemodialysis patients compared to standard care.

METHODS/DESIGN

This is a multicentre parallel arm block randomized controlled trial (RCT) of a four session group self management intervention for hemodialysis patients delivered by health care professionals compared to standard care. A total of 176 consenting adults maintained on hemodialysis for a minimum of 6 months will be randomized to receive the self management intervention or standard care. Primary outcomes are biochemical markers of clinical status and adherence. Secondary outcomes include general health related quality of life, disease-specific quality of life, mood, self efficacy and self-reported adherence. Outcomes will be measured at baseline, immediately post-intervention and at 3 and 9 months post-intervention by an independent assessor and analysed on intention to treat principles with linear mixed-effects models across all time points. A qualitative component will examine which aspects of program participants found particularly useful and any barriers to change.

DISCUSSION

The NKF-NUS intervention builds upon previous research emphasizing the importance of empowering patients in taking control of their treatment management. The trial design addresses weaknesses of previous research by use of an adequate sample size to detect clinically significant changes in biochemical markers, recruitment of a sufficiently large representative sample, a theory based intervention and careful assessment of both clinical and psychological endpoints at various follow up points. Inclusion of multiple dependent variables allows us to assess the broader impact on the intervention including both hard end points as well as patient reported outcomes. This program, if found to be effective, has the potential to be implemented within the existing renal services delivery model in Singapore, particularly as this is being delivered by health care professionals already working with hemodialysis patients in these settings who are specifically trained in facilitating self management in renal patients.