Course of symptoms and health-related quality of life during specialized pre-dialysis care

Exploring Patients' Perceptions About Chronic Kidney Disease and Their Treatment: A Qualitative Study

BACKGROUND

Unhelpful illness perceptions can be changed by means of interventions and can lead to improved outcomes. However, little is known about illness perceptions in patients with chronic kidney disease (CKD) prior to kidney failure, and no tools exist in nephrology care to identify and support patients with unhelpful illness perceptions. Therefore, this study aims to: (1) identify meaningful and modifiable illness perceptions in patients with CKD prior to kidney failure; and (2) explore needs and requirements for identifying and supporting patients with unhelpful illness perceptions in nephrology care from patients' and healthcare professionals' perspectives.

METHODS

Individual semi-structured interviews were conducted with purposive heterogeneous samples of Dutch patients with CKD (n = 17) and professionals (n = 10). Transcripts were analysed using a hybrid inductive and deductive approach: identified themes from the thematic analysis were hereafter organized according to Common-Sense Model of Self-Regulation principles.

RESULTS

Illness perceptions considered most meaningful are related to the seriousness (illness identity, consequences, emotional response and illness concern) and manageability (illness coherence, personal control and treatment control) of CKD. Over time, patients developed more unhelpful seriousness-related illness perceptions and more helpful manageability-related illness perceptions, caused by: CKD diagnosis, disease progression, healthcare support and approaching kidney replacement therapy. Implementing tools to identify and discuss patients' illness perceptions was considered important, after which support for patients with unhelpful illness perceptions should be offered. Special attention should be paid towards structurally embedding psychosocial educational support for patients and caregivers to deal with CKD-related symptoms, consequences, emotions and concerns about the future.

CONCLUSIONS

Several meaningful and modifiable illness perceptions do not change for the better by means of nephrology care. This underlines the need to identify and openly discuss illness perceptions and to support patients with unhelpful illness perceptions. Future studies should investigate whether implementing illness perception-based tools will indeed improve outcomes in CKD.

Clinical and patient-reported trajectories at end-of-life in older patients with advanced CKD

BACKGROUND

We explore longitudinal trajectories of clinical indicators, patient-reported outcomes, and hospitalizations, in the years preceding death in a population of older patients with advanced chronic kidney disease (CKD).

METHODS

The EQUAL study is a European observational prospective cohort study with an incident eGFR <20 ml/min per 1.73 m2 and ≥65 years of age. The evolution of each clinical indicator was explored using generalized additive models during the 4 years preceding death.

RESULTS

We included 661 decedents with a median time to death of 2.0 years (IQR 0.9-3.2). During the years preceding death, eGFR, Subjective Global Assessment score, and blood pressure declined, with accelerations seen at 6 months preceding death. Serum hemoglobin, hematocrit, cholesterol, calcium, albumin, and sodium values declined slowly during follow-up, with accelerations observed between 6 and 12 months preceding death. Physical and mental quality of life declined linearly throughout follow-up. The number of reported symptoms was stable up to 2 years prior to death, with an acceleration observed at 1 year prior to death. The rate of hospitalization was stable at around one hospitalization per person year, increasing exponentially at 6 months preceding death.

CONCLUSIONS

We identified clinically relevant physiological accelerations in patient trajectories that began ∼6 to 12 months prior to death, which are likely multifactorial in nature, but correlate with a surge in hospitalizations. Further research should focus on how to effectively use this knowledge to inform patient and family expectations, to benefit the planning of (end-of-life) care, and to establish clinical alert systems.

Responsiveness and minimal important change of seven PROMIS computerized adaptive tests (CAT) in patients with advanced chronic kidney disease

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS®) has the potential to harmonize the measurement of health-related quality of life (HRQL) across medical conditions. We evaluated responsiveness and minimal important change (MIC) of seven Dutch-Flemish PROMIS computerized adaptive tests (CAT) in Dutch patients with advanced chronic kidney disease (CKD).

METHODS

CKD patients (eGFR < 30 ml/min.1.73m²) completed at baseline and after 6 months seven PROMIS CATs (assessing physical function, pain interference, fatigue, sleep disturbance, anxiety, depression, and ability to participate in social roles and activities), Short Form Health Survey 12 (SF-12), PROMIS Pain Intensity single item, Dialysis Symptom Index (DSI), and Global Rating Scales (GRS) of change. Responsiveness was assessed by testing predefined hypotheses about expected correlations among measures, area under the ROC Curve, and effect sizes. MIC was determined with predictive modelling.

RESULTS

207 patients were included; 186 (90%) completed the follow-up. Most results were in accordance with expectations (70-91% of hypotheses confirmed), with some exceptions for PROMIS Anxiety and Ability to Participate (60% and 42% of hypotheses confirmed, respectively). For PROMIS Anxiety and Depression correlations with the GRS were too low (0.04 and 0.20, respectively) to calculate a MIC. MIC values, representing minimal important deterioration, ranged from 0.4 to 2.5 T-score points for the other domains.

CONCLUSION

We found sufficient responsiveness of PROMIS CATs Physical Function, Fatigue, Sleep Disturbance, and Depression. The results for PROMIS CATs Pain Interference were almost sufficient, but some results for Anxiety and Ability to Participate in Social Roles and Activities were not as expected. Reported MIC values should be interpreted with caution because most patients did not change.

Geriatric Syndromes and Health-Related Quality of Life in Older Adults with Chronic Kidney Disease

Key Points

In older adults with CKD, geriatric syndromes are common and are associated with reduced quality of life. Addressing geriatric syndromes could potentially improve quality of life for older adults with CKD.

Background

Geriatric syndromes, which are multifactorial conditions common in older adults, predict health-related quality of life (HRQOL). Although CKD is associated with lower HRQOL, whether geriatric syndromes contribute to HRQOL in CKD is unknown. Our objective was to compare associations of geriatric syndromes and medical conditions with HRQOL in older adults with CKD.

Methods

This was a secondary analysis of a parallel-group randomized controlled clinical trial evaluating a 12-month exercise intervention in persons 55 years or older with CKD stage 3b–4. Participants were assessed for baseline geriatric syndromes (cognitive impairment, poor appetite, dizziness, fatigue, and chronic pain) and medical conditions (diabetes, hypertension, coronary artery disease, cancer, or chronic obstructive pulmonary disease). Participants' HRQOL was assessed with the Short Form Health Survey-36 (SF-36), EuroQol 5-Dimensions 5-Level, and the EuroQol Visual Analogue Scale. We examined the cross-sectional and longitudinal associations of geriatric syndromes and medical conditions with HRQOL using multiple linear regression.

Results

Among 99 participants, the mean age was 68.0 years, 25% were female, and 62% were Black. Participants had a baseline mean of 2.0 geriatric syndromes and 2.1 medical conditions; 49% had ≥ two geriatric syndromes and ≥ two medical conditions concurrently. Sixty-seven (68%) participants underwent 12-month assessments. In models using geriatric syndromes and medical conditions as concurrent exposures, the number of geriatric syndromes was cross-sectionally associated with SF-36 scores for general health (β =−0.385) and role limitations because of physical health (β =−0.374) and physical functioning (β =−0.300, all P <0.05). The number of medical conditions was only associated with SF-36 score for role limitations because of physical health (β =−0.205).

Conclusions

In older adults with CKD stage 3b–4, geriatric syndromes are common and are associated with lower HRQOL. Addressing geriatric conditions is a potential approach to improve HRQOL for older adults with CKD.

Clinical Trial registry name and registration number:

NCT01462097 ; Registration Date–October 26, 2011.

Symptom Burden before and after Dialysis Initiation in Older Patients

BACKGROUND AND OBJECTIVES

For older patients with kidney failure, lowering symptom burden may be more important than prolonging life. Dialysis initiation may affect individual kidney failure-related symptoms differently, but the change in symptoms before and after start of dialysis has not been studied. Therefore, we investigated the course of total and individual symptom number and burden before and after starting dialysis in older patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality (EQUAL) study is an ongoing, prospective, multicenter study in patients ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m2. Using the dialysis symptom index (DSI), 30 symptoms were assessed every 3-6 months between 2012 and 2021. Scores for symptom number range from zero to 30 and, for burden, from zero to 150, with higher scores indicating more severity. Using mixed effects models, we studied symptoms during the year preceding and the year after dialysis initiation.

RESULTS

We included 456 incident patients on dialysis who filled out at least one DSI during the year before or after dialysis. At dialysis initiation, mean (SD) participant age was 76 (6) years, 75% were men, mean (SD) eGFR was 8 (3) ml/min per 1.73 m2, 44% had diabetes, and 46% had cardiovascular disease. In the year before dialysis initiation, symptom number increased +3.6 (95% confidence interval [95% CI], +2.5 to +4.6) and symptom burden increased +13.3 (95% CI, +9.5 to +17.0). In the year after, symptom number changed -0.9 (95% CI, -3.4 to +1.5) and burden decreased -5.9 (95% CI, -14.9 to -3.0). At dialysis initiation, "fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" had the highest prevalence of 81%, 69%, and 68%, respectively, with a burden of 2.7, 2.4, and 2.3, respectively. "Fatigue" somewhat improved after dialysis initiation, whereas the prevalence and burden of sexual symptoms further increased.

CONCLUSIONS

Symptom burden worsened considerably before and stabilized after dialysis initiation. "Fatigue," "decreased interest in sex," and "difficulty becoming sexually aroused" were considered most burdensome, of which only "fatigue" somewhat improved after dialysis initiation.

Predictors of somatic symptom persistence in patients with chronic kidney disease (SOMA.CK): study protocol for a mixed-methods cohort study

INTRODUCTION

Seven of 10 patients with non-dialysis chronic kidney disease (CKD) experience burdensome persistent somatic symptoms (PSS). Despite the high prevalence and relevance for quality of life, disease progression and mortality, the pathogenesis of PSS in CKD remains poorly understood. The SOMA.CK study aims to investigate biopsychosocial predictors and their interactions for PSS in non-dialysis CKD and to develop a multivariate prognostic prediction model for PSS in CKD.

METHODS AND ANALYSIS

The study is a mixed-methods cohort study with assessments at baseline, 6 and 12 months. It aims to include 330 patients with CKD stages G2-4 (eGFR=15-89 mL/min/1.73 m²). Primary outcome is the CKD-specific somatic symptom burden assessed with the CKD Symptom Burden Index. Secondary outcomes include quality of life, general somatic symptom burden and functioning. The interplay of biomedical (eg, biomarkers, epigenetics), treatment-related (eg, therapies and medication) and psychosocial variables (eg, negative affectivity, expectations) will be investigated to develop a prognostic prediction model for PSS. In an embedded mixed-methods approach, an experimental study in 100 patients using an affective picture paradigm will test the effect of negative affect induction on symptom perception. An embedded longitudinal qualitative study in 40-50 newly diagnosed patients will use thematic analysis to explore mechanisms of symptom development after receiving a CKD diagnosis. SOMA.CK is part of the interdisciplinary research unit 'Persistent SOMAtic Symptoms ACROSS Diseases'.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Hamburg Medical Association (2020-10195-BO-ff). Findings will be disseminated through peer-reviewed publications, scientific conferences, the involvement of our patient advisory board and the lay public. Focusing on subjective symptom burden instead of objective disease markers will fundamentally broaden the understanding of PSS in CKD and pave the path for the development of mechanism-based tailored interventions.

TRIAL REGISTRATION NUMBER

ISRCTN16137374.

Quality of Life before and after the Start of Dialysis in Older Patients

BACKGROUND AND OBJECTIVES

In older people with kidney failure, improving health-related quality of life is often more important than solely prolonging life. However, little is known about the effect of dialysis initiation on health-related quality of life in older patients. Therefore, we investigated the evolution of health-related quality of life before and after starting dialysis in older patients with kidney failure.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The European Quality study is an ongoing prospective, multicenter study in patients aged ≥65 years with an incident eGFR ≤20 ml/min per 1.73 m². Between April 2012 and December 2021, health-related quality of life was assessed every 3-6 months using the 36-item Short-Form Health Survey (SF-36), providing a mental component summary (MCS) and a physical component summary (PCS). Scores range from zero to 100, with higher scores indicating better health-related quality of life. With linear mixed models, we explored the course of health-related quality of life during the year preceding and following dialysis initiation.

RESULTS

In total, 457 patients starting dialysis were included who filled out at least one SF-36 during follow-up. At dialysis initiation, mean ± SD age was 76±6 years, eGFR was 8±3 ml/min per 1.73 m², 75% were men, 9% smoked, 45% had diabetes, and 46% had cardiovascular disease. Median (interquartile range) MCS was 53 (38-73), and median PCS was 39 (27-58). During the year preceding dialysis, estimated mean change in MCS was -13 (95% confidence interval, -17 to -9), and in PCS, it was -11 (95% confidence interval, -15 to -7). In the year following dialysis, estimated mean change in MCS was +2 (95% confidence interval, -7 to +11), and in PCS, it was -2 (95% confidence interval, -11 to +7). Health-related quality-of-life patterns were similar for most mental (mental health, role emotional, social functioning, vitality) and physical domains (physical functioning, bodily pain, role physical).

CONCLUSIONS

Patients experienced a clinically relevant decline of both mental and physical health-related quality of life before dialysis initiation, which stabilized thereafter. These results may help inform older patients with kidney failure who decided to start dialysis.

Trajectories of Uremic Symptom Severity and Kidney Function in Patients with Chronic Kidney Disease

BACKGROUND AND OBJECTIVES

Uremic symptoms, including fatigue, anorexia, pruritus, nausea, paresthesia, and pain, are attributed to the accumulation of organic waste products normally cleared by the kidneys, but whether kidney function is the primary driver of changes in symptom severity over time is not known. The goal of our study was to evaluate the association between eGFR and uremic symptom severity score in patients with CKD.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

We identified 3685 participants with CKD not on dialysis in the prospective, observational Chronic Renal Insufficiency Cohort (CRIC) Study with baseline assessment of eGFR and uremic symptom severity. Symptoms were assessed by separate questions on the Kidney Disease Quality of Life-36 instrument (zero- to 100-point scale). The longitudinal association between eGFR and uremic symptom severity score was examined with multivariable adjusted linear mixed-effects models with random intercepts and random slopes.

RESULTS

The mean±SD eGFR at baseline was 44±15 ml/min per 1.73 m2, and participants had a median of six (interquartile range 3-11) simultaneous assessments of eGFR and uremic symptoms over the duration of follow-up. The most prevalent symptoms at baseline were pain (57%), fatigue (52%), paresthesia (45%), and pruritus (42%). In adjusted models, a decrease in eGFR of 5 ml/min per 1.73 m2 was associated with a worsening of the symptom severity score by two points or less for each uremic symptom (P<0.01; zero- to 100-point scale). The association between eGFR and uremic symptom severity score was nonlinear. When starting from a lower initial eGFR, a 5 ml/min per 1.73 m2 decrease in eGFR was associated with a greater magnitude of uremic symptom worsening.

CONCLUSIONS

The prevalence of uremic symptoms in CKD is high, with significant variability in patient symptom change over time. Declines in eGFR were associated with worsening of uremic symptom severity, but the magnitude of these changes is small and of uncertain clinical significance.

Factors affecting health-related quality of life in older patients with chronic kidney disease: a single-center cross-sectional study

BACKGROUND

Health-related quality of life (HRQoL) assessment is important for patients with chronic kidney disease (CKD). However, few studies have examined factors related to HRQoL, such as physical function, in older patients with predialysis CKD. This study evaluated the relationship between physical function, renal function, and nutritional status on the HRQoL in this patient group.

METHODS

This cross-sectional study included 61 patients aged ≥ 65 years with stages 3-5 predialysis CKD who were admitted for CKD education purposes. Using the EuroQoL 5-dimension 5-level (EQ-5D-5L) health status measure, the percentages of each EQ-5D-5L item were investigated. Physical function was measured using the short physical performance battery (SPPB) and grip strength, and characteristics, such as age, sex, diabetes mellitus, estimated glomerular filtration rate, and Geriatric Nutrition Risk Index, were investigated. Factors associated with EQ-5D-5L were identified using multiple regression analysis.

RESULTS

More than half of respondents (34/61, 55.7%) selected the second or higher level "have a problem" for the pain/discomfort section. The EQ-5D-5L score was significantly correlated with grip strength (r = 0.34, p = 0.01) and SPPB (r = 0.59, p = 0.00) in a single correlation analysis. Only SPPB (β = 0.67, p = 0.00) remained a significant factor after adjustment for grip strength, SPPB, age, sex, diabetes mellitus, and estimated glomerular filtration rate.

CONCLUSION

Physical function may be an important factor influencing HRQoL in older patients with predialysis CKD.

A metabolomics approach identified toxins associated with uremic symptoms in advanced chronic kidney disease

Uremic symptoms are common in patients with advanced chronic kidney disease, but the toxins that cause these symptoms are unknown. To evaluate this, we performed a cross-sectional study of the 12 month post-randomization follow-up visit of Modification of Diet in Renal Disease (MDRD) participants reporting uremic symptoms who also had available stored serum. We quantified 1,163 metabolites by liquid chromatography-tandem mass spectrometry. For each uremic symptom, we calculated a score as the severity multiplied by the number of days the symptom was experienced. We analyzed the associations of the individual symptom scores with metabolites using linear models with empirical Bayesian inference, adjusted for multiple comparisons. Among 695 participants, the mean measured glomerular filtration rate (mGFR) was 28 mL/min/1.73 m². Uremic symptoms were more common in the subgroup of 214 patients with an mGFR under 20 mL/min/1.73 m² (mGFR under 20 subgroup) than in the full group. For all metabolites with significant associations, the direction of the association was concordant in the full group and the subgroup. For gastrointestinal symptoms (bad taste, loss of appetite, nausea, and vomiting), eleven metabolites were associated with symptoms. For neurologic symptoms (decreased alertness, falling asleep during the day, forgetfulness, lack of pep and energy, and tiring easily/weakness), seven metabolites were associated with symptoms. Associations were consistent across sensitivity analyses. Thus, our proof-of-principle study demonstrates the potential for metabolomics to understand metabolic pathways associated with uremic symptoms. Larger, prospective studies with external validation are needed.

Better health-related quality of life in kidney transplant patients compared to chronic kidney disease patients with similar renal function

Renal functional deterioration is associated with physical and mental burdens for kidney transplant (KT) and chronic kidney disease (CKD) patients. However, the change in health-related quality of life (HRQOL) over time in KT patients compared to that of native CKD patients has not been evaluated. We addressed this issue using KT patients registered in the KNOW-KT cohort study and patients at CKD stage 1–3 registered in the KNOW-CKD cohort study. HRQOL scores were assessed using the Kidney Disease Quality of Life Short Form at baseline, 2-, and 4-years follow-up in 842 KT patients and at baseline and 5-year follow-up in 1,355 CKD patients. SF-36 scores declined at the 4-year follow-up, whereas CKD-targeted scores showed no change in the KT group. In contrast, CKD-targeted scores as well as SF-36 scores were decreased at the 5-year follow-up in CKD patients. When prognostic factors were analyzed for longitudinal HRQOL data over time, renal functions, diabetes, cardiovascular and cerebrovascular diseases, hemoglobin level, marital status, income, employment, and health care were significant prognostic factors. Furthermore, KT was an independent prognostic factor for better HRQOL. These results highlight that KT can offer a better HRQOL than that of CKD patients, even when renal function is similar.

Person centred care provision and care planning in chronic kidney disease: which outcomes matter? A systematic review and thematic synthesis of qualitative studies : Care planning in CKD: which outcomes matter?

RATIONALE & OBJECTIVE

Explore priorities related to outcomes and barriers of adults with chronic kidney disease (CKD) regarding person centred care and care planning.

STUDY DESIGN

Systematic review of qualitative studies.

SEARCH STRATEGY & SOURCES

In July 2018 six bibliographic databases, and reference lists of included articles were searched for qualitative studies that included adults with CKD stages 1-5, not on dialysis or conservative management, without a previous kidney transplantation.

ANALYTICAL APPROACH

Three independent reviewers extracted and inductively coded data using thematic synthesis. Reporting quality was assessed using the COREQ and the review reported according to PRISMA and ENTREQ statements.

RESULTS

Forty-six studies involving 1493 participants were eligible. The period after diagnosis of CKD is characterized by feelings of uncertainty, social isolation, financial burden, resentment and fear of the unknown. Patients show interest in ways to return to normality and remain in control of their health in order to avoid further deterioration of kidney function. However, necessary information is often unavailable or incomprehensible. Although patients and healthcare professionals share the predominant interest of whether or not dialysis or transplantation is necessary, patients value many more outcomes that are often unrecognized by their healthcare professionals. We identified 4 themes with 6 subthemes that summarize these findings: 'pursuing normality and control' ('pursuing normality'; 'a search for knowledge'); 'prioritizing outcomes' ('reaching kidney failure'; 'experienced health'; 'social life'; 'work and economic productivity'); 'predicting the future'; and 'realising what matters'. Reporting quality was moderate for most included studies.

LIMITATIONS

Exclusion of non-English articles.

CONCLUSIONS

The realisation that patients' priorities do not match those of the healthcare professionals, in combination with the prognostic ambiguity, confirms fatalistic perceptions of not being in control when living with CKD. These insights may contribute to greater understanding of patients' perspectives and a more person-centred approach in healthcare prioritization and care planning within CKD care.

Fatigue in CKD: Epidemiology, Pathophysiology, and Treatment

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

Clinical events and patient-reported outcome measures during CKD progression: findings from the Chronic Renal Insufficiency Cohort Study

BACKGROUND

Patients with chronic kidney disease (CKD) face risks of not only end-stage kidney disease (ESKD), cardiovascular disease (CVD) and death, but also decline in kidney function, quality of life (QOL) and mental and physical well-being. This study describes the multidimensional trajectories of CKD using clinical events, kidney function and patient-reported outcome measures (PROMs). We hypothesized that more advanced CKD stages would associate with more rapid decline in each outcome.

METHODS

Among 3939 participants enrolled in the Chronic Renal Insufficiency Cohort (CRIC) Study, we evaluated multidimensional disease trajectories by G- and A-stages of enrollment estimated glomerular filtration rate (eGFR) and albuminuria, respectively. These trajectories included clinical events (ESKD, CVD, heart failure and death), eGFR decline and PROMs [kidney disease QOL (KDQOL) burden, effects and symptoms questionnaires, as well as the 12-item short form mental and physical component summaries]. We also evaluated a group-based multitrajectory model to group participants on the basis of longitudinal PROMs and compared group assignments by enrollment G- and A-stage.

RESULTS

The mean participant age was 58 years, 45% were women, mean baseline eGFR was 44 mL/min/1.73 m2 and median urine albumin:creatinine ratio was 52 mg/g. The incidence of all clinical events was greater and eGFR decline was faster with more advanced G- and A-stages. While baseline KDQOL and physical component measures were lower with more advanced G- and A-stage of CKD, changes in PROMs were inconsistently related to the baseline CKD stage. Groups formed on PROM trajectories were fairly distinct from existing CKD staging (observed agreement 60.6%) and were associated with the risk of ESKD, CVD, heart failure and death.

CONCLUSIONS

More advanced baseline CKD stage was associated with a higher risk of clinical events and faster eGFR decline, and was only weakly related to changes in patient-reported metrics over time.

Kidney function and symptom development over time in elderly patients with advanced chronic kidney disease: results of the EQUAL cohort study

BACKGROUND

Initiation of renal replacement therapy often results from a combination of kidney function deterioration and symptoms related to chronic kidney disease (CKD) progression. We investigated the association between kidney function decline and symptom development in patients with advanced CKD.

METHODS

In the European Quality study on treatment in advanced CKD (EQUAL study), a European prospective cohort study, patients with advanced CKD aged ≥65 years and a kidney function that dropped <20 mL/min/1.73 m2 were followed for 1 year. Linear mixed-effects models were used to assess the association between kidney function decline and symptom development. The sum score for symptom number ranged from 0 to 33 and for overall symptom severity from 0 to 165, using the Dialysis Symptom Index.

RESULTS

At least one kidney function estimate with symptom number or overall symptom severity was available for 1109 and 1019 patients, respectively. The mean (95% confidence interval) annual kidney function decline was 1.70 (1.32; 2.08) mL/min/1.73 m2. The mean overall increase in symptom number and severity was 0.73 (0.28; 1.19) and 2.93 (1.34; 4.52) per year, respectively. A cross-sectional association between the level of kidney function and symptoms was lacking. Furthermore, kidney function at cohort entry was not associated with symptom development. However, each mL/min/1.73 m2 of annual kidney function decline was associated with an extra annual increase of 0.23 (0.07; 0.39) in the number of symptoms and 0.87 (0.35; 1.40) in overall symptom severity.

CONCLUSIONS

A faster kidney function decline was associated with a steeper increase in both symptom number and severity. Considering the modest association, our results seem to suggest that repeated thorough assessment of symptom development during outpatient clinic visits, in addition to the monitoring of kidney function decline, is important for clinical decision-making.

Quality of Life and Symptom Burden among Chronic Kidney Disease of Uncertain Etiology (CKDu) Patients in Girandurukotte, Sri Lanka

Symptom burden and health-related quality of life (HRQOL) are important predictors of how a disease affects patients' lives, especially for endemic health problems such as chronic kidney disease of uncertain etiology (CKDu). Our study describes symptom burden, HRQOL, and associated demographic and clinical variables in CKDu patients in the Girandurukotte area, Sri Lanka. A cross-sectional study included 120 CKDu patients attending the renal clinic in the endemic area. The instruments applied were the Kidney Disease Quality of Life-Short Form (KDQOL-SFTM) version 1.3 and CKD Symptom Index-Sri Lanka. Socio-demographic, disease-related, and anthropometric variables were also investigated. The mean age of patients was 61.87 (SD 11.31), while 69.2% were male. The mean glomerular filtration rate was 28.17 (SD 14.03) mL/min/1.73 min2, and 70.8% were anemic. Bone/joint pain was the most experienced symptom while the median number of symptoms reported by patients was 5 (IQR 3-7). The mean symptom burden, physical component summary, mental component summary, and kidney-disease-specific component scores were 12.71 (SD 10.45), 68.63 (SD 19.58), 78.53 (SD 18.78), and 81.57 (SD 5.86), respectively. Age was found to be a significant predictor of HRQOL, while hemoglobin level and being a farmer were significant predictors of symptom burden. Our data indicate that CKDu patients in all stages experience at least one symptom affecting all aspects of HRQOL.

Trajectories of health-related quality of life among renal transplant patients associated with graft failure and symptom distress: Analysis of the BENEFIT and BENEFIT-EXT trials

Understanding the correlation between transplant symptoms, health-related quality of life (HRQoL), and graft outcomes is needed to support patient-focused drug development and posttransplant management. A post-hoc analysis of patient-reported outcomes from the Phase III belatacept trials was conducted in order to investigate the interrelationship between trajectories of HRQoL, symptom experience, and allograft outcomes. HRQoL and symptom experience were evaluated using Short-Form 36 Survey (SF-36) and Modified Transplant Symptom Occurrence and Distress Scale (MTSOSD-59R), respectively. HRQoL was captured in 831 eligible renal transplant patients at baseline, 12, 24, and 36 months posttransplant. Following transplantation, patients reported improvements in all SF-36 subscales compared to baseline. Latent class analysis revealed four trajectories in perceived general health, which were associated with graft failure after adjustment. Compared to patients with good perceived health, patients with fair and poor perceived health had 4.7 (95% confidence interval [CI] 1.5-14.8, P < .01) and 19.8 (95% CI 5.9-66.0, P < .01) times the risk of graft failure, respectively. Using multinomial logistic regression, different sets of symptoms were associated with perceived general health at baseline and 12 months posttransplant. The study supports monitoring HRQoL and symptom experience to capture each patient's health perspective, improve drug development, and optimize posttransplant management.

The impact of symptoms on health-related quality of life in elderly pre-dialysis patients: effect and importance in the EQUAL study

BACKGROUND

Quality of life (QoL) is an important outcome in chronic kidney disease (CKD). Patients feel that symptoms are an important determinant of QoL. However, this relation is unknown. The aims of this study were to investigate the impact of the number and severity of symptoms on QoL in elderly pre-dialysis patients, assessed by both the effect of symptoms and their importance relative to kidney function, and other clinical variables on QoL.

METHODS

The European Quality study (EQUAL study) is an ongoing European prospective follow-up study in late Stage 4/5 CKD patients aged ≥65 years. We used patients included between March 2012 and December 2015. Patients scored their symptoms with the Dialysis Symptom Index, and QoL with the research and development-36 (RAND-36) item Health Survey (RAND-36). The RAND-36 results in a physical component summary (PCS) and a mental component summary (MCS). We used linear regression to estimate the relation between symptoms and QoL at baseline and after 6 months, and to calculate the variance in QoL explained by symptoms.

RESULTS

The baseline questionnaire was filled in by 1079 (73%) patients (median age 75 years, 66% male, 98% Caucasian), and the follow up questionnaire by 627 (42%) patients. At baseline, every additional symptom changed MCS with -0.81 [95% confidence interval (CI): -0.91 to -0.71] and PCS with -0.50 (95% CI: -0.62 to -0.39). In univariable analyses, number of symptoms explained 22% of MCS variance and 11% of PCS variance, whereas estimated glomerular filtration rate only explained 1%.

CONCLUSIONS

In elderly CKD Stage 4/5 patients, symptoms have a substantial impact on QoL. This indicates symptoms should have a more prominent role in clinical decision-making.

Uraemic symptom burden and clinical condition in women and men of ≥65 years of age with advanced chronic kidney disease: results from the EQUAL study

BACKGROUND

The epidemiology and prognosis of chronic kidney disease (CKD) differ by sex. We aimed to compare symptom prevalence and the clinical state in women and men of ≥65 years of age with advanced CKD receiving routine nephrology care.

METHODS

The European QUALity study on treatment in advanced chronic kidney disease (EQUAL) study follows patients from six European countries of ≥65 years of age  years whose estimated glomerular filtration rate (eGFR) dropped to ≤20 mL/min/1.73 m2 for the first time during the last 6 months. The Dialysis Symptom Index was used to assess the prevalence and severity of 33 uraemic symptoms. Data on the clinical state at baseline were collected from medical records. Prevalence was standardized using the age distribution of women as the reference.

RESULTS

The results in women (n = 512) and men (n = 967) did not differ with age (77.0 versus 75.7 years) or eGFR (19.0 versus 18.5). The median number of symptoms was 14 [interquartile range (IQR) 9-19] in women, and 11 (IQR 7-16) in men. Women most frequently reported fatigue {39% [95% confidence interval (CI) 34-45]} and bone/joint pain [37% (95% CI 32-42)] as severe symptoms, whereas more men reported difficulty in becoming sexually aroused [32% (95% CI 28-35)] and a decreased interest in sex [31% (95% CI 28-35)]. Anaemia [73% (95% CI 69-77) versus 85% (95% CI 82-87)] was less common in women than in men, as were smoking history and cardiovascular comorbidity. However, a diagnosis of liver disease other than cirrhosis, psychiatric disease and mild malnutrition were more common among women.

CONCLUSIONS

Women in secondary care with an incident eGFR ≤20 mL/min/1.73 m2 reported a higher symptom burden, while their clinical state was considered similar or even more favourable as compared with men.

The Relationship Between Chronic Kidney Disease, Symptoms and Health-Related Quality of Life: A Systematic Review

BACKGROUND

People with chronic kidney disease (CKD) experience a wide range of symptoms due to reduced kidney function. As the disease progresses these symptoms become more burdensome and often negatively affect a person's health-related quality of life (HRQoL).

OBJECTIVE

To examine the evidence of symptoms and HRQoL in CKD stages 1-5 and the relationships between these.

METHODS

Studies published in English from January 2008 to July 2018 using six databases (PubMed, MEDLINE, CINAHL, PsycINFO, Cochrane Library and JBI Library) were searched.

RESULTS

Thirteen studies were included in this review although only three had interventional designs. By considering symptom experience and HRQoL together, four studies found that HRQoL decreased when symptoms increased. Feeling washed out, fatigue and drowsiness were found to be the most common symptoms reported. Only two studies reported follow-up measurements although six studied how symptoms change over time. None of the studies examined the change of symptoms over time across the different CKD stages. The majority of studies showed a decline in physical HRQoL and improvement in mental HRQoL over time. Nutritional and exercise interventions showed some improvements in symptom experience and HRQoL.

CONCLUSIONS

Only four studies were found that reported the relationship between symptoms and HRQoL of those with CKD. Of these, in view of symptom experience and HRQoL together, HRQoL decreased when symptoms increased. However, more research is warranted to establish a clear understanding of the relationship between symptoms and HRQoL in CKD to enable the design of appropriate interventions.

Reasons for Underreporting of Uremic Pruritus in People With Chronic Kidney Disease: A Qualitative Study

CONTEXT

Uremic pruritus, or itch, is common in people with chronic kidney disease (CKD) and has a negative impact on their lives and well-being. However, for reasons currently unknown, itch often remains unreported and therefore untreated.

OBJECTIVES

To explore reasons for underreporting of itch to provide pointers for improving itch reporting and management in people with CKD.

METHODS

We interviewed adult patients with CKD who self-reported experiencing itching in the last three years (n = 25), nephrologists (n = 10), and nurses (n = 12) from three kidney services in the U.K. Topic guides were informed by previous studies and a theoretical model of self-regulation. We conducted a thematic analysis of verbatim transcripts using framework analysis.

RESULTS

We identified the following three main themes reflecting factors that may influence whether itch is reported: knowledge on causes and treatment of itch (lack of awareness of the relationship between itch and CKD, and lack of knowledge of treatment options); attitudes toward importance of itch as a health issue (patients' and clinicians' attitudes); and prompts for itch assessment during consultations (routine practice, itch as a marker, and itch severity).

CONCLUSION

Underreporting of itch is related to patients being unaware of its causes, accepting it as something to live with, prioritizing other health issues, and the length and timing of consultations. Health care professionals' assessment and management of itch vary widely and are not necessarily evidence-based. Better patient information, development of clinical practice guidelines, and incorporation of routine symptom assessments into care may improve itch reporting and management in people with CKD.

Patient-reported outcome measures: selection of a valid questionnaire for routine symptom assessment in patients with advanced chronic kidney disease - a four-phase mixed methods study

Background

Patient-reported outcome measures (PROMs) are becoming increasingly important in healthcare. In nephrology, there is no agreement on which chronic kidney disease (CKD) symptom questionnaire to use. Therefore, the aim of this study is to select a valid symptom questionnaire for routine assessment in patients with advanced CKD.

Methods

A four-phase mixed methods approach, using qualitative and quantitative research methods, was applied. First, a systematic literature search was conducted to retrieve existing symptom questionnaires. Second, a symptom list was created including all symptoms in existing questionnaires and symptoms mentioned in interviews with patients with CKD, from which symptom clusters were identified. Next, questionnaires were selected based on predefined criteria regarding content validity. Last, two online feedback panels of patients with CKD (n = 151) and experts (n = 6) reviewed the most promising questionnaires.

Results

The literature search identified 121 questionnaires, of which 28 were potentially suitable for symptom assessment in patients with advanced CKD. 101 unique symptoms and 10 symptom clusters were distinguished. Based on predefined criteria, the Dialysis Symptom Index (DSI) and Palliative Care Outcome Scale-Renal Version (IPOS-Renal) were selected and reviewed by feedback panels. Patients needed 5.4 and 7.5 min to complete the DSI and IPOS-Renal, respectively (p < 0.001). Patients experienced the DSI as more specific, complete and straightforward compared to the IPOS-Renal.

Conclusions

The DSI was found to be valid and reliable, the most relevant, complete, and comprehensible symptom questionnaire available for routine assessment in patients with advanced CKD. Routine PROMs collection could be of great value to healthcare, both at individual patient and national level. Feedback on scores and involvement of healthcare providers may promote adaptation and implementation in healthcare.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1521-9) contains supplementary material, which is available to authorized users.

Changes in Symptom Burden in Dialysis Patients Assessed Using a Symptom-Reporting Questionnaire in Clinic

Introduction:

To determine the prevalence, severity, and change in symptoms experienced by dialysis patients following the introduction of use of a symptom-reporting questionnaire in nephrology clinic.

Methods:

This is an observational study of 160 prevalent dialysis patients. Palliative care Outcome Scale symptom (POS-renal) questionnaires modified for patients with end-stage kidney disease were completed at baseline and follow-up (median 3 months), with results available to nephrologists at clinic appointments.

Findings:

The baseline prevalence of individual symptoms ranged from 15% to 66%. The most common symptoms were lack of energy (66%) and poor mobility (58%). The median number of symptoms was 7/17 (interquartile range [IQR]: 4-10). Forty-nine percent of patients rated at least 1 symptom as severe or overwhelming. At follow-up, the median number of symptoms experienced was unchanged at 7/17 (IQR: 3-10). However, there was considerable flux in symptom severity. On average, individual symptoms that were present at baseline improved in 56% of patients and worsened in 18%; only 26% had stable symptom severity. Individual symptoms newly occurred in 8% to 20% of patients between time points, with 77% of patients experiencing at least 1 new symptom. The percent of patients rating at least 1 symptom as severe or overwhelming was reduced from 49% to 39% ( P = .040).

Conclusions:

Use of the POS-renal questionnaire identified a high symptom burden. The presence and severity of symptoms changed dramatically over a short follow-up period, highlighting the need for regular surveillance of symptoms in the dialysis population. Routine use of a symptom questionnaire in clinic may be useful for the identification and management of symptoms in dialysis patients.

Effects of Hemodialysis on the Symptom Burden of Terminally Ill and Nonterminally Ill End-Stage Renal Disease Patients

BACKGROUND

No study has compared the effects of hemodialysis on the symptom burden of terminally ill and nonterminally ill end-stage renal disease (ESRD) patients.

OBJECTIVES

This study aimed to examine the effects of hemodialysis on the symptom burden of ESRD patients and compare the terminally ill and nonterminally ill groups.

DESIGN

This was a quantitative survey; for patients on hemodialysis, the survey was conducted at the beginning and end of the weekly cycle of hemodialysis sessions.

SETTING/SUBJECTS

A total of 211 ESRD patients were recruited in Taiwan, 47 of which were terminally ill (38 on hemodialysis) and 164 nonterminally ill (110 on hemodialysis).

MEASUREMENTS

Symptom burden was assessed using the Taiwanese version of the MD Anderson Symptom Inventory for kidney disease.

RESULTS

Being terminally ill predicted higher symptom severity (B = 0.604, p = 0.017), whereas hemodialysis predicted lower symptom severity (B = -0.614, p = 0.014) in ESRD patients. Nonterminally ill patients who were married or on hemodialysis experienced lower symptom severity (B = -0.604, p = 0.013 and B = -0.665, p = 0.017, respectively). Among terminally ill patients, neither hemodialysis nor other background characteristics predicted symptom severity. When hemodialysis was initiated, no change in symptom severity was observed in terminally ill and nonterminally ill patients.

CONCLUSIONS

The effects of hemodialysis on symptom burden were different between ESRD patients with different disease states. Hemodialysis predicted lower symptom severity only in nonterminally ill ESRD patients. Apart from dialysis, care providers should revisit the palliative approach for treating terminally ill ESRD patients to improve their quality of life.

Symptom burden in patients with chronic kidney disease not requiring renal replacement therapy

BACKGROUND

Although evidence shows that patients with end stage renal disease (ESRD) experience a high symptom burden which impacts on quality of life (QoL), less is known about patients with earlier stages of chronic kidney disease (CKD). This study aimed to explore symptom burden and potential contributing factors in patients with CKD Stage 1-5 not requiring renal replacement therapy (RRT).

METHODS

Patients with CKD Stage 1-5 and not on RRT were asked to report their symptoms using the Leicester Uraemic Symptom Score (LUSS), a questionnaire which assesses the frequency and intrusiveness of 11 symptoms commonly reported by kidney patients.

RESULTS

Symptoms were assessed in 283 CKD Stage 1-5 patients: 54% male, mean age 60.5 standard error± 1.0, mean eGFR 38ml/min/1.73m2. Some 96% (95% confidence interval 93.2-98.0) of participants reported experiencing at least one symptom, the median reported being six. Excessive tiredness (81%;76.0-85.6), sleep disturbance (70%;64.3-75.3) and pain in bones/joints (69%;63.4-74.6) were reported most commonly. Overall, few significant associations were found between biochemical markers of disease severity and symptom burden. Men tended to report fewer symptoms than women and South Asian patients often described experiencing symptoms with a greater severity. Older patients found musculoskeletal symptoms more intrusive whereas younger patients found reduced concentration more intrusive.

CONCLUSIONS

Our findings suggest that patients with CKD stages 1-5 experience a multitude of symptoms that could potentially impact QoL. Using multidimensional tools like the LUSS, more exploration and focus could provide a greater opportunity for patient focussed symptom control from the earliest stages of CKD.

Incorporating patient-reported symptom assessments into routine care for people with chronic kidney disease

In this issue of Clinical Kidney Journal, Brown and colleagues show that symptom burden is high across all stages of chronic kidney disease (CKD). Still, management of symptoms in kidney patients leaves room for improvement, which may partly stem from symptoms being underreported. The use of patient-reported questionnaires may facilitate a more systematic approach to symptom assessment, but to date, the majority of these instruments have been used only in the context of research studies. In this editorial, we review how systematic patient-reported symptom assessments can be incorporated in CKD care. We show examples from an initiative in the UK where 14 renal units explored how to collect and use symptom burden assessments as part of their routine ways of working. We also discuss how to move from paper-based questionnaires towards digital collection of patient-reported symptom data. Lastly, we introduce wearable and smartphone sensors as novel methods for collecting information to support and enrich symptom assessments while minimizing data collection burden.

Nephrology pre-dialysis care affects the psychological adjustment, not only blood pressure, anemia, and phosphorus control

Several studies have suggested that pre-dialysis care is associated with clinical outcomes. However, little has been reported on the influence of pre-dialysis care on the psychological adjustment to dialysis. The purpose of this study was to evaluate the impact of pre-dialysis care on psychological adjustment to dialysis and clinical characteristics. In this cross-sectional study, we enrolled 52 patients who started hemodialysis at our hospital. They were divided into two groups according to the time of referral to our hospital: the early referral group (over 1 year prior to first dialysis: 19 patients, mean age 69.3 ± 11.1) and the late referral group (within 1 year prior to first dialysis: 33 patients, mean age 72.3 ± 8.9). We measured the clinical characteristics and evaluated the psychological adjustment to dialysis by Shontz's stage theory. Compared with the late referral group, the early referral group had a significantly better clinical characteristics concerning blood pressure (140.2 ± 23.7 vs. 156.9 ± 23.3 mmHg, P = 0.0150), hemoglobin (10.3 ± 1.5 vs. 9.4 ± 1.0 g/dL, P = 0.0078), and phosphorus (4.5 ± 1.5 vs. 5.5 ± 1.3 mg/dL, P = 0.0166). In addition, psychological adjustment to dialysis evaluated by Shontz's stage theory was significantly better in the early referral group (P = 0.017). Our results indicate that nephrology pre-dialysis care affects not only blood pressure, anemia, and phosphorus control but also the psychological adjustment to dialysis.