The prevalence of symptoms in end-stage renal disease: a systematic review

Treatment of insomnia, restless legs, cramps, and pain associated with chronic kidney disease: results from a multinational survey of kidney supportive care practice

BACKGROUND

Kidney failure is associated with a high symptom burden, yet few studies describe real-world management approaches.

METHODS

Kidney care units in Australia, New Zealand (NZ) and the United Kingdom (UK) were surveyed regarding their pharmacological treatment of a range of common symptoms affecting those with kidney failure. The present report describes the results for insomnia, restless legs syndrome (RLS), cramps, and pain. Variation in responses was described using normalised generalised variance (NGV), resulting in a score from 1 (most diverse) to 0 (least diverse).

RESULTS

One hundred and twelve (of 171 contacted) kidney units responded, including 56 units in Australia (50%), 7 in NZ (6%), and 49 in the UK (44%). Diversity of practice was highest for insomnia (mean NGV 0.95, range 0.93-0.98), where melatonin was the leading first-line agent (38%), followed by zolpidem and zopiclone (29%). Diversity of practice was lowest for RLS (mean NGV 0.66, range 0.30-0.99), owing to widespread use of iron replacement as first line (69%), gabapentinoids (45%), and dopamine agonists (37%). Diversity of practice was moderate for neuropathic pain (mean NGV 0.71, range 0.44-0.93), cramps (mean NGV 0.72, range 0.48-0.97), and opioids (mean NGV 0.88, range 0.75-0.97). Numerous significant between-country differences in treatment preferences were noted.

CONCLUSIONS

There is wide variation in treatment approaches to common symptoms affecting people living with advanced CKD or kidney failure, both within and between countries, indicating a need for evidence-based guidelines and further randomised studies to inform practice.

CLINICAL TRIAL NUMBER

Not applicable.

Effects of inspiratory muscle training on dyspnea and lung capacity in patients with chronic kidney disease on hemodialysis: a systematic review and meta-analysis

INTRODUCTION

Inspiratory muscle training (IMT) is an alternative to improve the respiratory condition of hemodialysis (HD) patients with respiratory muscle weakness.

OBJECTIVE

To evaluate the effect of IMT on dyspnea and lung capacity in dialysis patients.

METHOD

A systematic review of randomized controlled trials (RCTs) which evaluated the effects of IMT in dialysis patients on the outcomes of dyspnea, lung capacity, respiratory muscle strength and dialysis effectiveness index (Kt/V) was conducted. The searches were conducted in February 2025 and were performed in the Medline/PubMed, Cochrane Library, LILACS, CINAHL, PEDro, Web of Science, Embase and Google Scholar databases. Study quality was assessed using the Cochrane RoB2 tool.

RESULTS

Six studies were analyzed (n = 210). One study showed an improvement in dyspnea [4.17   ±   0.58; 95%CI (0.0073-0.884); p = .022], and the meta-analyses found a mean difference of 0.34 L/min [95%CI (0.08-0.61); p = .010] in forced vital capacity (FVC) and 25.15 cmH2O [95%CI (17.05-33.24); p < .001] in maximum inspiratory pressure (MIP) in the IMT groups. There was no difference in Kt/V. Only one study showed a low risk of bias.

CONCLUSION

IMT in patients with CKD on HD improved dyspnea, FVC and MIP. Considering the low quality of the studies, new RCTs with greater methodological rigor are needed.

Investigation of the Effect of Reiki on Pain, Fatigue, and Itching in Hemodialysis Patients: Randomized Controlled Trial

INTRODUCTION

The management of symptoms associated with hemodialysis, which adversely affect patients, increases their quality of life. Complementary integrative therapies such as Reiki are used in symptom management. This study aimed to investigate the effects of Reiki on pain, fatigue, and itching in hemodialysis patients.

METHODS

The study had a randomized controlled design and was conducted in three dialysis centers with a total of 74 hemodialysis patients, 37 in the intervention group, and 37 in the control group. A total of 10 sessions of Reiki were administered to the patients in the intervention group twice a week for 5 weeks, while the patients in the control group received routine hemodialysis treatment. The data of the study were collected using the Patient Identification Form, the Patient Clinical Parameters Form, the Visual Analog Scale, the McGill Pain Questionnaire, the Piper Fatigue Scale, and the 5-D Itch Scale.

FINDINGS

It was determined that there was a statistically significant decrease in the pain, fatigue, and itching levels of the patients in favor of the intervention group in the second and third measurements (p < 0.05). Although there was no change in the pain and fatigue levels of the patients in the control group, the levels of itching increased statistically and significantly (p < 0.05).

DISCUSSION

The findings suggest that Reiki has an effect on pain, fatigue, and itching in hemodialysis patients.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05531175.

A pilot randomized controlled study of integrated kidney palliative care and chronic kidney disease care implemented in a safety-net hospital: Protocol for a pilot study of feasibility of a randomized controlled trial

Background

Chronic kidney disease (CKD) impacts more than 800 million people. It causes significant suffering and disproportionately impacts marginalized populations in the United States. Kidney palliative care has the potential to alleviate this distress, but has not been tested. This pilot study evaluates the feasibility of a randomized clinical trial (RCT) testing the efficacy of integrated kidney palliative and CKD care in an urban safety-net hospital.

Methods

This is a single-site pilot RCT designed to enroll 85 participants, with a goal of at least 60 completing the study. The inclusion criteria are adults 18 or older, who are either Spanish or English speakers, have an estimated Glomerular Filtration Rate (eGFR) of ≤30 mL/min/1.73 m2, and are receiving care at our safety net hospital. Participants will be randomized in permuted blocks of two or four to either the intervention group, who will receive monthly ambulatory care visits for six months with a palliative care provider trained in kidney palliative care, or to usual nephrology care. Primary outcomes are feasibility of recruitment, retention, fidelity to the study visit protocol, and the ability to collect outcome data. These outcomes include symptom burden, quality of life, and engagement in advance care planning.

Discussion

This pilot RCT will provide essential data on the feasibility of testing integrated palliative care in CKD care in an underserved setting. These outcomes will inform a larger, fully powered trial that tests the efficacy of our kidney palliative care approach.

Clinical trial registration

NCT04998110.

Effect of online hemodiafiltration on quality of life, fatigue and recovery time: a systematic review and meta-analysis

The present systematic review and meta-analysis aims to compare the effect of bicarbonate hemodialysis and HDF on quality of life (QoL), fatigue, and time to recovery in end-stage renal disease (ESRD) patients. Searches were run on January 2024 and updated on 3 March 2024 in the following databases: Ovid MEDLINE (1985 to present); Ovid EMBASE (1985 to present); Cochrane Library (Wiley); PubMed (1985 to present). Ten articles were fully assessed for eligibility and included in the investigation. Compared to HD, online HDF had a pooled MD of the mental component score (MCS) of the SF-36 of 0.98 (95% CI - 0.92, 2.87; P = 0.31). and of the physical component score (PCS) of 0.08 (95% CI - 1.32, 1.48; P = 0.91). No significant heterogeneity was observed (Chi2 = 4.85; I2 = 38%; P = 0.18 and Chi2 = 3.85; I2 = 22%; P = 0.28, respectively). Studies that compared the QoL assessed through the Kidney Disease Questionnaire or KDQOL-SF and show that HDF does not improve QoL when compared with HD, in most studies. In five out of seven studies, HDF was not significantly more effective than HD in improving fatigue. The length of the recovery time resulted in similar in patients receiving HDF and HD in all studies included in the present review. HDF is not more effective than HD in improving QoL and fatigue and in reducing the length of time of recovery after dialysis.

Sleep disturbances in adults with chronic kidney disease: an umbrella review

BACKGROUND

This umbrella review aimed to synthesise the existing evidence on sleep disturbances and sleep disorders in the adult chronic kidney disease (CKD) population.

METHODS

A systematic search across five electronic databases. Reviews were grouped according to aspects of sleep and the focus of the review. The JBI critical appraisal checklist was used for quality assessment, and Preferred Reporting Items for Overviews of Reviews (PRIOR) guideline was used for reporting. The protocol was registered in the international registry PROSPERO (CRD42024527039).

RESULTS

We identified 50 reviews covering three main aspects of sleep (sleep apnoea, restless legs syndrome and other sleep disturbances) across five focus areas (prevalence, interventions, health outcomes, determinants of sleep and patient experience). Most reviews reported on sleep disturbances (72%, 36 reviews) and focused on interventions (58%, 29 reviews). In contrast, evidence on sleep determinants and patient experience was limited. A high prevalence of sleep apnoea (49%), restless legs syndrome (27.2%) and other sleep disturbances (55%) was reported. Non-pharmacological interventions, including aromatherapy, dialysis, muscle relaxation, yoga, music, and nurse-led management, were found to improve sleep. However, this evidence was based on a single meta-analysis with few primary studies.

CONCLUSIONS

Despite the growing number of reviews on interventions to improve sleep, the evidence for their effectiveness is limited by the small number of primary studies and the high degree of overlap between reviews. Further research is needed to identify effective interventions. Additionally, qualitative studies exploring patients' perspectives on sleep are essential, as evidence in this area remains scarce.

Using Ecological Momentary Assessment to Redefine Postdialysis Fatigue in Patients with Kidney Failure

Background:

Patients with kidney failure have a high symptom burden and many report an acute exacerbation of symptoms immediately following in-center hemodialysis (HD). Very few studies have used ecological momentary assessment (EMA) to examine post-HD patient-centered outcomes.

Methods:

Participants in the Technology Assisted Collaborative Care (TĀCcare) trial completed an automated telephone-administered Daytime Insomnia Symptom Scale (DISS) at 4 time points daily for 7 consecutive days. The DISS yields 4 symptom domain scores: Positive Mood, Negative Mood, Alert Cognition, and Sleepiness/Fatigue. Post-HD symptom domains and item-level scores were compared to similar time points on non-HD days using linear mixed models analyses. Mixed models were also used to explore the association of post-dialysis symptom burden with demographic, psychosocial, hemodialysis treatment, and disease-specific characteristics. All analyses were adjusted for age, race, sex, and Charlson Comorbidity Index

Results:

156 HD patients with available EMA data were evaluated [mean age=58±14 years, 55% men, 51% White]. In the post-HD period, patients reported significantly lower Positive Mood [mean difference (MD)= -0.22, 95% CI (-0.29, -0.14)] and Alert Cognition [MD= -0.13, 95% CI (-0.18, -0.08)] and higher Negative Mood [MD=0.12, 95% CI (0.05, 0.19)] and Sleepiness/Fatigue [MD=0.51, 95% CI (0.42, 0.61)] compared to non-HD days. The mean post-dialysis symptom exacerbation total score was 0.70 ± 1.21, representing an increase of 6% of the maximum scale range. In the post-dialysis period, relative to non-dialysis days, the mean decrease in Positive Mood and Alert Cognition scores equaled 4% and 2% of the maximum scale range respectively; the mean increase in Negative Mood and Sleepiness/Fatigue scores equaled 2% and 9% of the maximum scale range respectively.

Conclusions:

Patients with kidney failure reported worsening of both fatigue and mood symptoms post- HD.

Why do most people on dialysis not accept psychological care to increase perceptions of control in life?

OBJECTIVES

People with chronic kidney failure (CKF) on dialysis who perceive little control in life are at risk for a reduced well-being. We developed and tested an intervention aiming to enhance their perceptions of control. To gain insight into patients' care needs and acceptance of the intervention, we examined the prevalence of patients perceiving low control, their characteristics, and their reasons for (not) accepting the intervention.

DESIGN

We consecutively screened 430 people on dialysis on perceived control, with those reporting low control offered to participate in the intervention study.

METHODS

We used data of a Randomized Controlled Trial examining the feasibility, acceptability and efficacy of the intervention. Perceived control was assessed with the Pearlin Mastery scale.

RESULTS

About half (55%) of the sample perceived low control, particularly those with more comorbidities. Most persons eligible for receiving the intervention did not accept the intervention (89%), especially older persons. Main reasons were experiencing little burden of perceiving low control as well as no need for care to increase perceived control.

CONCLUSIONS

A significant number of people on dialysis perceived low control in life, yet very few accepted an intervention for regaining a sense of control. In-depth qualitative research is needed for a more comprehensive understanding of the personal experience and perceived impact of low control on health and well-being, activities and relationships as well as people's reasons and needs for enhancing a sense of control and attitude towards psychological interventions aiming to enhance perceived control.

Exploring Chronic Pain in Hemodialysis Patients: An Observational Study Based on the New IASP Classification for ICD-11

INTRODUCTION

Pain is one of the most frequently reported symptoms in hemodialyzed (HD) patients, with prevalence rates between 33% and 82%. Risk factors for chronic pain in HD patients are older age, long-lasting dialysis history, several concomitant diseases, malnutrition, and others. However, chronic pain assessment in HD patients is rarely performed by specialists in pain medicine, with relevant consequences in terms of diagnostic and treatment accuracy. Furthermore, no study has used the recently introduced International Association for the Study of Pain (IASP) pathophysiological classification.

METHODS

In this observational, cross-sectional study in a tertiary HD center in Northern Italy, we analyzed data regarding HD patients, evaluated for 5 months in 2021 by specialists in pain medicine and aimed to identify and characterize chronic pain according to the IASP definition and the last 2019 classification of chronic pain for ICD-11. Pain severity was evaluated by the pain severity score of the brief pain inventory tool.

RESULTS

Among 213 patients, 65 (31%) suffered from chronic pain. The average age was 73.1 years; 55.5% of the patients were male; 53.7% had diabetes, and 39.2% had arterial hypertension. Of the 54 patients subjected to an in-depth evaluation, data regarding 113 pain diagnoses were extracted, particularly related to osteoarthritis, obliterating arterial disease, and low back pain with or without radiculopathy. On the basis of these diagnoses, the pain classification according to the IASP pathophysiological definition highlighted a predominant nociceptive pain type (53.9% of all the diagnoses), followed by neuropathic (22.1%), mixed (22.1%), nociplastic (2.6%), and idiopathic (2.6%) pain. According to the IASP classification for ICD-11, the clinical diagnosis of chronic pain secondary to obliterating arterial disease and diabetes-related foot ulcers could not be assigned to any diagnostic category as a result of the lack of a specific item in the aforementioned classification.

CONCLUSION

This study confirmed that chronic pain is a common, burdening issue in hemodialysis patients and that it is of a prevalent nociceptive nature. Our study highlights some limitations of the last IASP ICD-11 classification, especially the lack of specific items for some pain features that are very frequent in hemodialysis patients, and not only in that population. Finally, this study underlines the importance of mutual collaboration between pain physicians and nephrologists for the well-being of patients of high clinical complexity, such as those undergoing chronic hemodialysis.

Online peer-to-peer health communities for individuals affected by chronic kidney disease: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify and describe research exploring online peer-to-peer health communities for individuals affected by chronic kidney disease.

INTRODUCTION

The proliferation of online peer-to-peer health communities has created new opportunities for individuals affected by chronic kidney disease to come together for mutual social, emotional, and informational support.

INCLUSION CRITERIA

This scoping review will include qualitative, quantitative, mixed methods, and evidence synthesis studies, as well as gray literature relating to online peer-to-peer health communities for individuals affected by chronic kidney disease. The search will not be limited by language, time frame, geographic location, or publication date.

METHODS

This review will be undertaken in accordance with the JBI methodology for scoping reviews and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. The following databases will be searched: Cochrane Register of Controlled Trials (CENTRAL), CINAHL (EBSCOhost), Embase (Ovid), MEDLINE (Ovid), PsycINFO (Ovid), and Web of Science. Gray literature will be searched via MedNar, Google Scholar, and ProQuest Dissertations and Theses. After duplicates have been removed, 2 reviewers will independently screen the titles, abstracts, and full text of the eligible sources. Data will be extracted using a modified data extraction tool as per JBI guidance, and presented in tabular format, accompanied by a narrative summary describing how the findings relate to the scoping review questions.

REVIEW REGISTRATION

Open Science Framework https://osf.io/kfj9v.

Our Unrealized Imperative: Integrating Mental Health Care into Hospice and Palliative Care

The field of Hospice and Palliative Medicine (HPM) has its roots in the principles, promulgated by Dame Cicely Saunders, that patient and family are the unit of care and that comprehensive integration of physical, psychological, social, and spiritual care is necessary to address suffering in all its dimensions. Although we aspire to provide comprehensive care for our patients, most hospice and palliative care (HPM) physicians lack basic competencies for identifying and managing patients with psychological distress and mental health distress and disorders, a growing segment of our clinical population. In this article, I argue that we are not living up to the founding values of our field in how we practice, how we educate our trainees, our research, and in how we pursue our own professional development as faculty. The history of our field, the nature of our clinical workforce, the culture of PC, and our educational programs all contribute to our current practice model, which is not adequate to meet the mental health needs of our patients. I propose strategies to address these challenges focused on enhancing integration between psychiatry/psychology and HPM, changes in fellowship education and faculty development, addressing the stigma against people with mental health diagnoses, and addressing system and cultural challenges that limit our ability to provide the kind of comprehensive, integrative care that our field aspires to.

Cluster of symptoms in kidney failure: A systematic review

Background

Chronic kidney disease is a global problem characterized by a progressive decrease in kidney function with associated symptoms. A better understanding of these symptoms could lead to the development of personalized strategies.

Objective

This systematic review aims to describe the clusters of symptoms in kidney failure and categorize them according to their time of onset and how disabling they are for patients.

Design

A systematic review was carried out.

Methods

This systematic review was conducted according to the PRISMA declaration standards. The search engines used were initially limited to WOS, Embase, and PubMed, and they were employed between November 2022 and January 2023. In addition, the bibliographic search was supplemented with databases of the grey literature, such as OpenGrey, in May 2023. The following inclusion criteria were established: cross-sectional studies, studies on adult populations, and studies dealing with clusters of symptoms associated with kidney failure. Before an article was definitively selected, the checklist of the STROBE initiative, with a maximum of 22 points, was applied, assessing the quality of cross-sectional articles. Articles were selected independently and blinded by two researchers, and a third researcher was involved in case of disagreement.

Results

After carrying out the bibliographic search, we found that eight articles, out of the 46 articles that were evaluated, fully met the inclusion criteria. Two tables were made, which include important information, such as the participants' profiles or the way the authors extracted a cluster of symptoms.

Limitations

The main area for improvement is that it was not possible to perform a meta-analysis due to the methodology used in the articles analysed. Constraining the selection of articles to those written in Spanish or English could be a limitation as not all articles dealing with symptom clusters in kidney failure were considered.

Conclusions

Common symptoms in clusters of symptoms in kidney failure were nausea or vomiting (gastrointestinal problems), fatigue or muscle weakness (neuromuscular symptoms/problems), low interest in sex or difficulty feeling sexually excited (sexual symptoms), dry skin or skin itching (skin problems), lack of appetite, feeling squeezed, feeling weak or dizzy and difficulty breathing (uraemic), fatigue or muscle weakness (energy/vitality), and chest pain (cardiac-related problems). Providing treatment based on clusters of symptoms would benefit the patient more than providing treatment based on isolated symptoms. The identification of symptom clusters in kidney failure has clinical relevance, and this research could facilitate the development of adequate intervention strategies, simplifying the treatment offered to patients and even reducing the side effects of treatments.

Determinants of Longitudinal Changes in Exercise Capacity in Patients With Independent Functioning on Hemodialysis

OBJECTIVE

Patients with chronic kidney disease reportedly have decreased muscle oxygen utilization, which most substantially decreases exercise capacity, followed by cardiac reserve. However, determinants of longitudinal changes in exercise capacity in patients on hemodialysis (HD) and the effects of long-term exercise interventions (EI) are unknown. This study was conducted to clarify these concerns.

METHODS

This was a prospective cohort study. Patients on HD that were not hospitalized were followed from baseline up to 2 years, and cardiopulmonary exercise testing results, including peak oxygen uptake, peak work rate, heart rate reserve, and ventilatory equivalent for carbon dioxide slope, as well as implementation of EI were assessed. Based on the 2-year change in peak oxygen uptake, they were divided into improvement or declined groups.

RESULTS

Forty-five patients who were not hospitalized completed the follow-up were analyzed. In the improvement group, the variation was determined by an increase in peak work rate, which is a peripheral factor (partial regression coefficient 0.08 [95% CI = 0.01 to 0.16]), while in the decline group, the variation was determined by a decrease in the ventilatory equivalent for carbon dioxide slope, which is a cardiac factor (partial regression coefficient = -0.12; 95% CI = -0.21 to -0.03). Moreover, exercise intervention was associated with the change in peak oxygen uptake (partial regression coefficient = 3.09; 95% CI = 1.45 to 4.72).

CONCLUSION

Exercise intolerance even in patients on HD that were not hospitalized and stable progressed over time with deterioration of cardiac reserve, whereas EI were associated with improved exercise capacity through enhanced peripheral function.

IMPACT

The results support the early measurement of cardiopulmonary or skeletal muscle reserve through cardiopulmonary exercise testing and the implementation of long-term EI based on the measurement results to address the potential deterioration in exercise capacity associated with reduced cardiac reserve, even in patients on HD that are asymptomatic and stable.

Psychological wellbeing and treatment adherence among cardio-renal syndrome patients in Yemen: a cross section study

Background

Anxiety and depression are associated with adverse outcomes in cardiorenal syndrome patients undergoing hemodialysis, including decreased quality of life, poorer clinical parameters, and lower treatment adherence.

Objective

This study aimed to examine the level of psychological wellbeing and its relationship with treatment adherence among dialysis patients with cardiorenal syndrome.

Methods

This cross-sectional descriptive study was conducted between February and May 2021 on convenience sampling of 100 patients in two dialysis centers in Hadhramout, Yemen. Patients' depression and anxiety levels were assessed using the Hospital Anxiety and Depression Scale (HADS)-Arabic version, and patient treatment adherence was assessed using the Treatment Adherence Questionnaire (TAQ). Descriptive statistics, Pearson's correlation analysis, and multiple linear regression analyzes were performed to analyze data with a significance level set at p < 0.05.

Results

The mean age ± standard deviation of participants was 53.46 ± 14.24 years. Most (90%) of patients had moderate to high levels of anxiety and depression. Most of the patients (87%) had a low level of treatment adherence. The findings revealed that psychological wellbeing is significantly association with treatment adherence t = 2.577 (95% CI 0.029, 0.225), p = 0.011.

Conclusion

Anxiety and depression symptoms occurred more frequently among dialysis patients with cardiorenal syndrome, and there was a significant association between psychological wellbeing and treatment adherence. Our findings suggest that nurse managers should take into account that adding psychotherapies into the present cardiorenal syndrome treatment programs would improve patients' clinical and psychological parameters and, consequently, their clinical outcomes while taking patient heterogeneity and resource limitations into consideration.

A systematic review of symptoms experienced by children and young people with kidney failure

BACKGROUND

Kidney failure at any age has a significant impact on quality of life (QoL) but the overall symptom burden for children and young people (CYP) is poorly described. Kidney failure has no cure and whilst transplantation is the preferred management option, it is not always possible, with patients requiring supportive care at the end of their lives.

AIM

To use the literature to understand the symptom burden for CYP with kidney failure who are approaching end-of-life.

METHODS

Using three databases, a systematic literature review was performed to identify eligible studies to extract data on symptoms experienced in CYP aged < 21 years with kidney failure. Data extraction was completed by two authors using a pre-designed proforma. Study quality assessment was undertaken using the BMJ AXIS tool.

RESULTS

A total of 20,003 titles were screened to yielding 35 eligible studies including 2,862 CYP with chronic kidney disease (CKD), of whom 1,624 (57%) had CKD stage 5. The studies included a median of 30 (range 7-241) patients. Symptoms were subcategorised into eight groups: sleep, mental health, gastrointestinal, dermatology, ear, nose and throat (ENT), neurology, multiple symptoms, and ophthalmology. The prevalences of the most commonly reported symptoms were: restless leg syndrome 16.7-45%, sleep disordered breathing 20-46%, hypersomnia 14.3-60%, depression 12.5-67%, anxiety 5.3-34%, overall gastrointestinal symptoms 43-82.6%, nausea and vomiting 15.8-68.4%, abdominal pain 10.5-67.4%, altered appetite or anorexia 19-90%, xerosis 53.5-100%, pruritis 18.6-69%, headache 24-76.2% and ophthalmological symptoms 26%. Within each subgroup, the symptom definitions used were heterogeneous, the methods of assessment were varied and some symptoms, such as pain and constipation, were poorly represented.

CONCLUSIONS

There is a marked lack of evidence relating to the symptom burden for CYP with CKD. This study highlights the high symptom prevalence, particularly in relation to sleep, mental health, headache, dermatological and gastrointestinal symptoms. There is a need for consensus recommendations on the evaluation and management of symptoms for CYP with CKD approaching end-of-life.

PROSPERO ID

CRD42022346120.

Constipation and risk of death and cardiovascular events in patients on hemodialysis

BACKGROUND

Constipation is a common gastrointestinal disorder and is often accompanied by alteration in the gut microbiota. Recently, several studies have disclosed its association with an increased risk of cardiovascular disease and mortality in the general population. Despite the high prevalence of constipation, data on the clinical impact of constipation in patients with chronic kidney disease are limited. We aimed to explore the prevalence of constipation and its association with cardiovascular disease in chronic kidney disease using a nationally representative cohort of hemodialysis patients.

METHODS

This study used hemodialysis quality assessment and health insurance claims data from patients undergoing maintenance hemodialysis in South Korea. Chronic constipation was defined using the total number of laxatives prescribed during the 1-year baseline period. The primary outcome was a composite of acute ischemic stroke, hemorrhagic stroke, myocardial infarction, or all-cause death. Secondary outcomes were the individual components of the primary outcome.

RESULTS

Among 35,230 patients on hemodialysis, 9,133 (25.9%) were identified as having constipation. During a median follow-up of 5.4 years, patients with constipation had a 15% higher incidence of the composite outcome, 16% higher incidence of ischemic stroke, and 14% higher all-cause mortality, after multivariate adjustment.

CONCLUSION

Chronic constipation requiring laxatives was associated with a higher risk of the composite outcome of cardiovascular events or all-cause death in patients on hemodialysis. Further studies are needed to confirm whether constipation is an independent predictor or a possible causal factor of cardiovascular disease.

End-stage organ disease-Healthcare utilisation: Impact of palliative medicine

OBJECTIVES

Although patients living with end-stage organ disease (ESOD) suffer unmet needs from the physical and emotional burdens of living with chronic illness, they are less likely to receive palliative care.The aims of the study were to determine if palliative care referrals reduced healthcare utilisation and if impact on healthcare utilisation was dependent on the timing of the referral.

METHODS

Patients with ESOD who received palliative care support were matched with those who did not using coarsened exact matching and propensity score matching, and compared in this retrospective cohort study. Primary outcomes of interests were reduction in all-cause emergency department (ED) visits and costs, reduction in all-cause tertiary hospital admissions, length of hospital stay and inpatient hospital costs.

RESULTS

Patients with ESOD referred to palliative care experienced a reduction in the frequency of all cause ED visits and inpatient hospital admissions. Significant impact of a palliative care referral was at 3 months, rather than 1 month prior to death with a greater reduction in the frequency of ED visits, inpatient hospital admissions, length of stay and charges (p all <0.05). The most common ESOD referred to palliative care for 1110 matched patients was end-stage renal failure (57.7%), and least commonly for respiratory failure (7.6%).

CONCLUSION

Palliative care can reduce healthcare utilisation, with reduction greatest when the referral is timed earlier in the disease trajectory. Cost savings can be judiciously redirected to the development of palliative care resources for integrated support of patients and caregivers.

Current status and development trends in CKD with frailty research from 2000 to 2021: a bibliometric analysis

INTRODUCTION

The prevalence of chronic kidney disease (CKD) is gradually increasing in the elderly population. At the same time, frailty has become one of the research hotspots in the field of geriatrics. Bibliometric analyses help to understand the direction of a field. Therefore, this study aimed to analyze the status and emerging trends of frailty in CKD patients.

DATA AND METHODS

The Web of Science Core Collection (WoSCC) database was screened for relevant literature published between 1 January 2000 and 31 December 2021. Next, publications were analyzed for information including authors, journals, cited references, citing journals, institutions, countries and regions, high-frequency keywords and co-citations using VOSviewer, Microsoft Excel, and R software.

RESULTS

A total of 2223 articles were obtained, from which 613 relevant articles were selected based on title and abstract screening. There was an upward trend in the number of annual publications and Johansen KL was considered the most contributing author in the field. The Clinical Journal of the American Society of Nephrology was the most productive research journal. Johns Hopkins University is the most published organization. The United States is the global leader in the field and contributes the most to research. Research hotspots focus on epidemiological studies of frailty and frailty intervention.

CONCLUSIONS

This study presents a comprehensive bibliometric analysis of CKD and frailty research. Key findings highlight the current focus on early screening and assessment of frailty in CKD patients, as well as physical function interventions in frail patients.

Symptom Burden and Its Impact on Quality of Life in Patients With Moderate to Severe CKD: The International Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps)

RATIONALE & OBJECTIVE

Recent evidence suggests people with nondialysis chronic kidney disease (ND-CKD) experience a substantial burden of symptoms, but informative large-scale studies have been scarce. We assessed the prevalence of symptoms and the association of overall symptom burden with quality of life in patients with moderate to severe CKD.

STUDY DESIGN

Cross-sectional study.

SETTING & PARTICIPANTS

4,430 patients with ND-CKD stages 3-5 enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) in Brazil, France, and the United States between 2013 and 2021.

EXPOSURE

13 individual patient-reported symptoms from the Kidney Disease Quality of Life Short Form (KDQOL-SF) questionnaire and an overall symptom burden score (low, intermediate, and high).

OUTCOME

Physical and mental component summary scores (PCS and MCS) of the KDQOL-SF.

ANALYTICAL APPROACH

Adjusted prevalence ratios and generalized estimating equations.

RESULTS

Patients (mean age, 68 years; 40% women; mean baseline estimated glomerular filtration rate [eGFR], 30mL/min/1.73m2) were very much to extremely bothered by numerous symptoms ("soreness in muscles," 23%; "washed out or drained," 21%; "cramps, shortness of breath, dry skin, diminished sex life, or numbness in hands or feet," 14%-17%). The adjusted prevalences of "cramps," "washed out or drained," "lack of appetite," "nausea/upset stomach," and "sex life" were greater with more severe CKD and in women (except for "sex life"). A high overall symptom burden was more common in women, in France, and in patients with severe albuminuria and various comorbidities, but not with lower eGFR. The PCS and MCS scores were 13.4 and 7.7 points lower, respectively, for high versus low overall symptom burden.

LIMITATIONS

Generalizability limited to patients under nephrology care, residual confounding, and inaccurate Brazilian translation of some symptoms.

CONCLUSIONS

The high symptom burden observed in this large cohort of ND-CKD patients across 3 diverse countries and its strong association with poorer health-related quality of life should inform clinical management of and clinical research in CKD.

PLAIN-LANGUAGE SUMMARY

Little is known about symptoms in patients with non-dialysis-dependent chronic kidney disease (ND-CKD). In the Chronic Kidney Disease Outcomes and Practice Patterns Study, which enrolled 4,430 patients with CKD stages 3-5 in Brazil, France, and the United States, patients most often reported soreness in muscles, feeling washed out or drained, cramps, shortness of breath, dry skin, altered sex life, and numbness in hands or feet. Cramps, feeling washed out or drained, lack of appetite, and nausea were more often reported at lower levels of kidney function. The overall symptom burden was higher in women than men, in French than in Brazilian or US patients, and in those with severe albuminuria. The higher the symptom burden, the lower were the physical and mental health quality of life scores. The high symptom burden observed in this large cohort of ND-CKD patients across 3 diverse countries and its strong association with poorer health-related quality of life should inform clinical management of and clinical research in CKD.

The Effect of the Holy Quran Recitation on Inflammatory Markers in Hemodialysis Patients in Iran: A Randomized Clinical Trial

Increased inflammation is a common complication in chronic hemodialysis (HD) patients. Addressing the psychological symptoms of patients may help reduce inflammation and its negative impact on the body. Considering the calming effects of listening to the Holy Quran, this may help reduce mental, psychological, and physical problems in Muslim patients. The present study sought to examine the effects of listening to Holy Quran recitation on the level of inflammatory markers in HD patients. This was a randomized controlled trial involving 50 HD patients at Kowsar Hospital in Semnan, Iran, in 2019-2020. The participants were divided into experimental and control groups using simple randomization by sealed envelopes. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and interleukin-6 (IL-6) levels in blood were measured before the intervention. The participants in the experimental group listened by headphones to the Holy Quran being recited three times a week, 20 min each time, for one month. For those in the control group, headphones were placed but on silent mode. At the end of the intervention one month later, inflammatory markers were measured again for participants in both groups. Data were analyzed in SPSS-16 using descriptive and inferential statistics (t test, Wilcoxon, and Mann-Whitney U). Mean IL-6 level decreased by 20.2 pg/ml, mean ESR level by 16.8 mm/hr, and mean CRP level by 19.9 mg/dl in the experimental group, while these values increased in the control group. The between-group differences in the intervention and control groups at follow-up were significant for all three inflammatory markers (p < 0.05). Listening to the Holy Quran being recited is recommended as a complementary therapy for reducing systemic inflammation (as indicated by inflammatory markers) in Muslim HD patients.Trial registration: Iranian Registry of Clinical Trials, Trial No: IRCT20120109008665N9. Registered 4 Nov 2019.

Gut physiology and environment explain variations in human gut microbiome composition and metabolism

The human gut microbiome is highly personal. However, the contribution of gut physiology and environment to variations in the gut microbiome remains understudied. Here we performed an observational trial using multi-omics to profile microbiome composition and metabolism in 61 healthy adults for 9 consecutive days. We assessed day-to-day changes in gut environmental factors and measured whole-gut and segmental intestinal transit time and pH using a wireless motility capsule in a subset of 50 individuals. We observed substantial daily fluctuations, with intra-individual variations in gut microbiome and metabolism associated with changes in stool moisture and faecal pH, and inter-individual variations accounted for by whole-gut and segmental transit times and pH. Metabolites derived from microbial carbohydrate fermentation correlated negatively with the gut passage time and pH, while proteolytic metabolites and breath methane showed a positive correlation. Finally, we identified associations between segmental transit time/pH and coffee-, diet-, host- and microbial-derived metabolites. Our work suggests that gut physiology and environment are key to understanding the individuality of the human gut microbial composition and metabolism.

Exploring symptom clusters in Chinese patients with peritoneal dialysis: a network analysis

BACKGROUND

In recent years, the research on symptom management in peritoneal dialysis (PD) patients has shifted from a single symptom to symptom clusters and network analysis. This study collected and evaluated unpleasant symptoms in PD patients and explored groups of symptoms that may affect PD patients with a view to higher symptom management.

METHODS

The symptoms of PD patients were measured using the modified Dialysis Symptom Index. The symptom network and node characteristics were assessed by network analysis, and symptom clusters were explored by factor analysis.

RESULTS

In this study of 602 PD patients (mean age 47.8 ± 16.8 years, 47.34% male), most had less than 2 years of dialysis experience. Five symptom clusters were obtained from factor analysis, which were body symptom cluster, gastrointestinal symptom cluster, mood symptom cluster, sexual disorder symptom cluster, and skin-sleep symptom cluster. Itching and decreased interest in sex may be sentinel symptoms, and being tired or lack of energy and feeling anxious are core symptoms in PD patients.

CONCLUSIONS

This study emphasizes the importance of recognizing symptom clusters in PD patients for better symptom management. Five clusters were identified, with key symptoms including itching, decreased interest in sex, fatigue, and anxiety. Early intervention focused on these symptom clusters in PD patients holds promise for alleviating the burden of symptoms.

Feasibility and acceptability of the ShareD dEciSIon making for patients with kidney failuRE to improve end-of-life care intervention: A pilot multicentre randomised controlled trial

Background

Kidney failure is associated with a high disease burden and high mortality rates. National and international guidelines recommend health professionals involve patients with kidney failure in making decisions about end-of-life care, but implementation of these conversations within kidney services varies. We developed the DESIRE (ShareD dEciSIon-making for patients with kidney failuRE to improve end-of-life care) intervention from our studies investigating multiple decision maker needs and experiences of end-of-life care in kidney services. The DESIRE intervention's three components are a training programme for health professionals, a patient decision aid, and a kidney service consultation held to facilitate shared decision-making conversations about planning end-of-life care.

Objectives

To assess the feasibility and acceptability of integrating the DESIRE intervention within kidney services.

Design

A pilot study using a multicentre randomised controlled design.

Setting

Four Danish nephrology departments.

Participants

Patients with kidney failure who were 75 years of age or above, their relatives, and health professionals.

Methods

Patients were randomised to either the intervention or usual care. Feasibility data regarding delivering the intervention, the trial design, and outcome measures were collected through questionnaires and audio recordings at four points in time: before, during, post, and 3 months after the intervention. Acceptability data were collected through semi-structured interviews with patients and relatives, as well as a focus group with health professionals post the intervention.

Results

Twenty-seven patients out of the 32 planned were randomised either to the intervention (n= 14) or usual care (n= 13). In addition, four relatives and 12 health professionals participated. Follow-up was completed by 81 % (n= 22) of patient participants. We found that both feasibility and acceptability data suggested health professionals improved their decision support and shared decision-making skills via the training. Patient and relative participants experienced the intervention as supporting a shared decision-making process; from audio recordings, we showed health professionals were able to support proactively decision-making about end-of-life care within these consultations. All stakeholders perceived the intervention to be effective in promoting shared decision-making and relevant for supporting end-of-life care planning.

Conclusions

Participant feedback indicated that the DESIRE intervention can be integrated into practice to support patients, relatives, and health professionals in planning end-of-life care alongside the management of worsening kidney failure. Minimising exhaustion and enhancing engagement with the intervention should be a focus for subsequent refinement of the intervention.

Registration

The study has been registered at ClinicalTrials.gov with the identifier: NCT05842772. Date of first recruitment: March 20, 2023.

Dialysis for Chronic Kidney Failure: A Review

Importance

More than 3.5 million people worldwide and 540 000 individuals in the US receive maintenance hemodialysis or peritoneal dialysis for the treatment of chronic kidney failure. The 5-year survival rate is approximately 40% after initiation of maintenance dialysis.

Observations

Hemodialysis and peritoneal dialysis remove metabolic waste and excess body water and rebalance electrolytes to sustain life. There is no recommended estimated glomerular filtration rate (eGFR) threshold for initiating dialysis, and patient-clinician shared decision-making should help determine when to initiate dialysis. Persistent signs and symptoms of uremia (eg, nausea, fatigue) and volume overload (eg, dyspnea, peripheral edema), worsening eGFR, metabolic acidosis, and hyperkalemia inform the timing of therapy initiation. A randomized clinical trial reported no mortality benefit to starting dialysis at higher eGFR (10-14 mL/min/1.73 m2) vs lower eGFR (5-7 mL/min/1.73 m2) levels. Observational data suggested no differences in 5-year mortality with use of hemodialysis vs peritoneal dialysis. Cardiovascular (eg, arrhythmias, cardiac arrest) and infection-related complications of maintenance dialysis are common. In the US, hemodialysis catheter-related bloodstream infections occur at a rate of 1.1 to 5.5 episodes per 1000 catheter-days and affect approximately 50% of patients within 6 months of catheter placement. Peritonitis occurs at a rate of 0.26 episodes per patient-year and affects about 30% of individuals in the first year of peritoneal dialysis therapy. Chronic kidney failure-related systemic complications, such as anemia, hyperphosphatemia, hypocalcemia, and hypertension, often require pharmacologic treatment. Hypotension during dialysis, refractory symptoms (eg, muscle cramps, itching), and malfunction of dialysis access can interfere with delivery of dialysis.

Conclusions and Relevance

In 2021, more than 540 000 patients in the US received maintenance hemodialysis or peritoneal dialysis for treatment of chronic kidney failure. Five-year survival rate after initiation of maintenance dialysis is approximately 40%, and the mortality rate is similar with hemodialysis and peritoneal dialysis. Decisions about dialysis initiation timing and modality are influenced by patient symptoms, laboratory trajectories, patient preferences, and therapy cost and availability and should include shared decision-making.

Intestinal microbiome changes and mechanisms of maintenance hemodialysis patients with constipation

Background

Constipation is a common symptom in maintenance hemodialysis patients and greatly affects the quality of survival of hemodialysis patients. Fecal microbiota transplantation and probiotics are feasible treatments for functional constipation, but there is still a gap in the research on the characteristics of gut flora in patients with maintenance hemodialysis combined with constipation. The aim of this study is to clarify the characteristics of the intestinal flora and its changes in maintenance hemodialysis patients with constipation.

Methods

Fecal samples were collected from 45 participants, containing 15 in the maintenance hemodialysis constipation group,15 in the maintenance hemodialysis non-constipation group and 15 in the healthy control group. These samples were analyzed using 16S rRNA gene sequencing. The feature of the intestinal microbiome of maintenance hemodialysis constipation group and the microbiome differences among the three groups were elucidated by species annotation analysis, α-diversity analysis, β-diversity analysis, species difference analysis, and predictive functional analysis.

Results

The alpha diversity analysis indicated that maintenance hemodialysis constipation group was less diverse and homogeneous than maintenance hemodialysis non-constipation group and healthy control group. At the genus level, the top ten dominant genera in maintenance hemodialysis constipation group patients were Enterococcus, Escherichia-Shigella, Bacteroides, Streptococcus, Bifidobacterium, Ruminococcus_gnavus_group, Lachnospiraceae_unclassified, Faecalibacterium, Akkermansia and UCG-002. Compared with non-constipation group, the Enterococcus, Rhizobiales_unclassified, Filomicrobium, Eggerthella, Allobaculum, Prevotella_7, Gordonibacter, Mitochondria_unclassified, Lachnoanaerobaculum were significantly higher in constipation group (p<0.05). Compared with non-constipation group, the Kineothrix, Rhodopirellula, Weissella were significantly lower in constipation group (p<0.05). The predictive functional analysis revealed that compared with non-constipation group, constipation group was significantly enriched in pathways associated with pyruate metabolism, flavonoid biosynthesis.

Conclusions

This study describes for the first time the intestinal microbiome characteristics of maintenance hemodialysis patients with constipation. The results of this study suggest that there is a difference in the intestinal flora between maintenance hemodialysis patients with constipation and maintenance hemodialysis patients without constipation.

The impact of severe depression on the survival of older patients with end-stage kidney disease

BACKGROUND

Incidence of depression increases in patients with end-stage kidney disease (ESKD). We evaluated the association between depression and mortality among older patients with ESKD, which has not been studied previously.

METHODS

This nationwide prospective cohort study included 487 patients with ESKD aged >65 years, who were categorized into minimal, mild-to-moderate, and severe depression groups based on their Beck Depression Inventory-II (BDI-II) scores. Predisposing factors for high BDI-II scores and the association between the scores and survival were analyzed.

RESULTS

The severe depression group showed a higher modified Charlson comorbidity index value and lower serum albumin, phosphate, and uric acid levels than the other depression groups. The Kaplan-Meier curve revealed a significantly lower survival in the severe depression group than in the minimal and mild-to-moderate depression groups (p = 0.011). Multivariate Cox regression analysis confirmed that severe depression was an independent risk factor for mortality in the study cohort (hazard ratio, 1.39; 95% confidence interval, 1.01-1.91; p = 0.041). Additionally, BDI-II scores were associated with modified Charlson comorbidity index (p = 0.009) and serum albumin level (p = 0.004) in multivariate linear regression. Among the three depressive symptoms, higher somatic symptom scores were associated with increased mortality.

CONCLUSION

Severe depression among older patients with ESKD increases mortality compared with minimal or mild-to-moderate depression, and patients with concomitant somatic symptoms require careful management of their comorbidities and nutritional status.

Assessing Daily Function and Sleep Disorders in Hemodialysis Patients with End-Stage Renal Disease

BACKGROUND

Chronic, end-stage renal disease significantly impacts patients' daily activities and sleep quality, particularly those undergoing hemodialysis. However, there is limited research on the extent of these challenges and their correlation with this population.

AIM

This study aims to assess the level of activity of daily living and the prevalence of sleep disturbances in patients with end-stage renal disease undergoing hemodialysis.

METHOD

A cross-sectional study involved 130 patients receiving hemodialysis in two public General Hospitals in Greece. The Barthel Index was used to measure daily living activity, while the Athens Insomnia Scale assessed sleep disorders. The data were analyzed using SPSSV25.0.

RESULTS

Of the 210 questionnaires, 130 were returned fully completed (response rate 62%). Most of the sample participants suffered from comorbidities (76.9%). The total Barthel Index score showed moderate dependence for patients, significantly related to the years and hours of dialysis (p = 0.007 and p = 0.000, respectively). The total score of the Athens Insomnia Scale was also significantly associated with age (p = 0.029), marital status (p = 0.015) and the years and hours of hemodialysis (p = 0.004 and p = 0.001, respectively). A statistically significant difference was recorded between the daily activity of patients with end-stage renal failure and their sleep quality (p = 0.000) Finally, the physical activity level of the participants was related to the existence of another physical health (p = 0.000) or mental health problem (p = 0.000).

CONCLUSIONS

Hemodialysis patients with chronic, end-stage renal disease experience significant challenges in maintaining daily activities and are prone to sleep disorders. These findings suggest a need for integrated care strategies that address both physical function and sleep quality to improve the overall well-being of this population.

Diurnal and Daily Symptom Variation in Patients with End Stage Kidney Disease: An Ecological Momentary Assessment Study

Key Points

Patients treated with maintenance hemodialysis report a higher symptom burden on the days they receive hemodialysis treatment, compared with non-hemodialysis days. The severity of physical, cognitive, and mood symptoms can vary diurnally, and the pattern of this variation may differ between hemodialysis and non-hemodialysis days. Ecological momentary assessment can provide insights into the complex, dynamic symptom experiences of patients on hemodialysis.

Background

Patients with ESKD on hemodialysis experience a high symptom burden, which is compounded by unpredictable fluctuations in symptom severity. Few studies have used ecological momentary assessment to determine how symptoms vary over time. This study aimed to characterize the diurnal and day-to-day variability in symptoms among patients receiving hemodialysis.

Methods

Patients enrolled in the Technology-Assisted Collaborative Care trial rated the intensity of physical, cognitive, and mood symptoms using an automated telephone-administered version of the Daytime Insomnia Symptom Scale at four time points (morning, early afternoon, late afternoon, evening) for seven consecutive days at baseline. Confirmatory factor analysis was used to verify the original four-factor solution for the Daytime Insomnia Symptom Scale: sleepiness/fatigue (SF), alert cognition (AC), positive mood (PM), and negative mood (NM). Symptom domain scores were calculated for each time point, and mixed modeling with random patient effects was used to examine differences in daily symptoms at daily time points between hemodialysis and non-hemodialysis days after controlling for age, sex, race, and comorbidity burden.

Results

One hundred sixty patients were enrolled (mean±SD age 58±14 years, 45% women, 52% White). Diurnal symptom variation existed; trends were nonlinear and differed by hemodialysis versus non-hemodialysis days. Day-to-day symptom variation also existed; patients endorsed better physical, cognitive, and mood states (i.e ., higher AC and PM) as well as lower symptom burden (i.e ., lower SF and NM) on non-hemodialysis days compared with hemodialysis days at all time points. The greatest day-to-day mean differences (MDs) were observed in the early afternoon for all symptom domains: AC (MD=0.17 P < 0.001), PM (MD=0.28, P < 0.001), SF (MD=−0.66, P < 0.001), and NM (MD=−0.26, P < 0.001).

Conclusions

Patients with ESKD demonstrate diurnal variation in symptoms and greater symptom burden on hemodialysis days compared with non-hemodialysis days, with the most extreme differences in symptom severity occurring in the early afternoon.

Clinical Trial registration number:

ClinicalTrials.gov NCT03440853 .

Association between Chronic Kidney Disease-Mineral and Bone Disorder Biomarkers and Symptom Burden in Older Patients with Advanced Chronic Kidney Disease: Results from the EQUAL Study

Key Points

In nondialysis patients with advanced CKD, mild-to-moderately increased parathyroid hormone is associated with lower levels of reported symptoms. Phosphate and calcium are not independently associated with overall symptom burden. Patients with both severe hyperphosphatemia and severe hyperparathyroidism had the highest symptom burden.

Background

Patients with advanced CKD develop numerous symptoms, with a multifactorial origin. Evidence linking mineral disorders (CKD-Mineral and Bone Disorder) and uremic symptoms is scant and mostly limited to dialysis patients. Here, we aim to assess the association between CKD-Mineral and Bone Disorder and symptom burden in nondialysis patients with CKD.

Methods

We used data from the European Quality study, which includes patients aged ≥65 years with eGFR ≤20 ml/min per 1.73 m2 from six European countries, followed up to 5 years. We used generalized linear mixed-effect models to determine the association between repeated measurements of parathyroid hormone (PTH), phosphate, and calcium with the overall symptom number (0–33), the overall symptom severity (0–165), and the presence of 33 CKD-related symptoms. We also analyzed subgroups by sex, age, and diabetes mellitus and assessed effect mediation and joint effects between mineral biomarkers.

Results

The 1396 patients included in the study had a mean of 13±6 symptoms at baseline, with a median overall severity score of 32 (interquartile range, 19–50). The association between PTH levels and symptom burden appeared U-shaped with a lower symptom burden found for mild-to-moderately increased PTH levels. Phosphate and calcium were not independently associated with overall symptom burden. The highest symptom burden was found in patients with a combination of both severe hyperparathyroidism and severe hyperphosphatemia (+2.44 symptoms [0.50–4.38], P = 0.01). The association of both hypocalcemia and hyperphosphatemia with symptom burden seemed to differ by sex and age.

Conclusions

In older patients with advanced CKD not on dialysis, mild-to-moderately increased PTH was associated with a lower symptom burden, although the effect size was relatively small (less than one symptom). Neither phosphate nor calcium were associated with the overall symptom burden, except for the combination of severe hyperphosphatemia and severe hyperparathyroidism which was associated with an increased number of symptoms.

Investigating Factors Influencing Kidney Transplant Decisions in Patients on Chronic Hemodialysis: A Study at Shiraz University of Medical Sciences

OBJECTIVES

End-stage renal disease is a health concern around the world. Kidney transplant substantially improves survival compared with dialysis. Although kidney transplant is the better choice for treatment of end-stage renal disease, most patients refuse this option. In this study, we aimed to find the most common reasons why patients did not undergo a kidney transplant.

MATERIALS AND METHODS

We conducted a cross-sectional study involving 263 patients on chronic hemodialysis in hemodialysis centers in Shiraz, Iran, in 2024. We collected data via structured interviews, which had questions on demographics, disease characteristics, dialysis details, and reasons for transplant refusal. P < .05 was considered significant.

RESULTS

In our study cohort, mean age was 60.2 ± 16.8 years and 57.8% were male patients. The most prevalent reason for refusing kidney transplant was patient-centric barriers for kidney transplant (47.7%); difficulties with the transplant process included financial concern (33.7%), unacceptability of outcomes (30.2%), and worries about the unpredictability of transplant outcome (24.1%). The mean age of patients on the kidney transplant waiting list was 51.7 ± 16.4 years, and mean age of those who declined a kidney transplant was 60.2 ± 16.8 years (P < .001). Among patients on the waiting list, 68.7% were married compared with 81.7% of patients who declined a kidney transplant (P = .011).

CONCLUSIONS

Addressing financial concerns by possibly improving insurance coverage, enhancing patient education on transplant benefits and risks, and providing psychological support can potentially increase acceptance rates. Tailored interventions focusing on individual patient concerns and improving communication between health care providers and patients are essential.

Frequent hemodialysis versus standard hemodialysis for people with kidney failure: Systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Frequent hemodialysis provided more than three times per week may lower mortality and improve health-related quality of life. Yet, the evidence is inconclusive. We evaluated the benefits and harms of frequent hemodialysis in people with kidney failure compared with standard hemodialysis.

METHODS

We performed a systematic review of randomized controlled trials including adults on hemodialysis with highly sensitive searching in MEDLINE, Embase, CENTRAL, and Google Scholar on 3 January 2024. Data were pooled using random-effects meta-analysis. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. We adjudicated evidence certainty using GRADE.

RESULTS

From 11,142 unique citations, only seven studies involving 518 participants proved eligible. The effects of frequent hemodialysis on physical and mental health were imprecise due to few data. Frequent hemodialysis probably had uncertain effect on death from all cause compared with standard hemodialysis (relative risk 0.79, 95% confidence interval 0.33-1.91, low certainty evidence). Data were not reported for death from cardiovascular causes, major cardiovascular events, fatigue or vascular access.

CONCLUSION

The evidentiary basis for frequent hemodialysis is incomplete due to clinical trials with few or no events reported for mortality and cardiovascular outcome measures and few participants in which patient-reported outcomes including health-related quality of life and symptoms were reported.

The effect of a caring program based on the Pender's health promotion model on caregiver burden in family caregivers of patients with chronic heart failure: A quasi-experimental study

BACKGROUND

The Pender's Health Promotion Model is a comprehensive solution to improve health and reduce the risk of chronic conditions. This study aimed to determine the effect of a care program based on the Pender's Health Promotion Model on the caregiving burden of family caregivers of patients with chronic heart failure.

METHODS

This semi-experimental study with a control group was conducted at the Imam Khomeini Heart Clinic in Saqqez in 2022-2023. In this study, 90 family caregivers from patients with chronic heart failure were randomized to intervention and control groups. Data were collected through a demographic information questionnaire and the Caregiver Burden Inventory (CBI) prior to and 50 days after the intervention. Data were analyzed using independent t-test, Chi-square, and paired t-test in SPSS V 25. A significance level of 5% was considered.

RESULTS

The results of this study indicated that the control and intervention groups were homogeneous in terms of demographic characteristics (P = 0.643). The findings also showed a statistically significant difference in the mean scores of all dimensions of caregiving burden between the two groups after the intervention, such that the overall mean score of caregiving burden in the intervention group had a significant reduction (P < 0.0001).

CONCLUSION

The present study demonstrated that a care program based on the Pender's Health Promotion Model can reduce the caregiving burden of family caregivers of patients suffering from chronic heart failure. Additionally based on health policies, this program can play an effective role in improving the quality of life of families with chronic heart failure patients and reducing their medical costs as a comprehensive solution for improving health and reducing the risk of chronic diseases.

Shared decision making for patients with kidney failure to improve end-of-life care: Development of the DESIRE intervention

AIM

To describe the development of a shared decision making intervention for planning end-of-life care for patients with kidney failure, their relatives and health professionals in kidney services.

BACKGROUND

End-of-life care conversations within standard disease management consultations are challenging for patients with kidney failure, their relatives and health professionals. End-of-life care planning is about making difficult decisions in advance, which is why health professionals need shared decision making skills to be able to initiate end-of-life conversations. Health professionals report needing more skills to raise the issue of end-of-life care options within consultations and patients want to be able to discuss issues important to them about future care plans.

METHODS

The development design was guided by the UK Medical Research Council's framework and a user-centred approach was applied. Four workshops were conducted with end users. The Template for Intervention Description and Replication for Population Health and Policy interventions was used to shape which questions needed to be answered through the workshops and to present the intervention. The International Patient Decision Aid Standards (IPDAS) criteria set the standards to be achieved.

RESULTS

Areas considered significant to a shared decision making intervention were training of health professionals, conversations about end-of-life care, planning and evaluation of the decisions, reporting decisions in health records and repetition of consultation. The development process went through 14 iterations.

CONCLUSION

An intervention named DESIRE was developed that comprises: (1) a training programme for health professionals; (2) shared decision making conversations; and (3) a patient decision aid. The intervention met 30 out of 33 IPDAS criteria.

IMPLICATIONS FOR PRACTICE

DESIRE is intended to support shared decision making about planning end-of-life care among patients with kidney failure, their relatives and health professionals. The study provides important tools for the stakeholders engaged that can be used within different models of care.

IMPACT

What problem did the study address? International guidelines recommend health professionals involve patients with kidney failure in making decisions about end-of-life care, but there is variation in how this is implemented within and across kidney services. Furthermore, patients, relatives and health professionals find it challenging to initiate conversations about end-of-life care. What were the main findings? The study resulted in the development of a complex intervention, called DESIRE, about shared decision making and planning end-of-life care for patients with kidney failure, their relatives and health professionals in kidney services, including a training programme for health professionals, shared decision making conversations and a patient decision aid. Where and on whom will the research have an impact? The research contributes a shared decision making intervention to patients in the later stage of kidney failure, their relatives and health professionals. We believe that the DESIRE intervention could be introduced during consultations with health professionals at an earlier stage of the patient's illness trajectory, as well as being applied to other chronic diseases.

REPORTING METHOD

This intervention development research is reported according to the GUIDance for the rEporting of intervention Development (GUIDED) checklist and the DEVELOPTOOLS Reporting Checklist.

PATIENT OR PUBLIC CONTRIBUTION

Patients, relatives and health professionals have been involved throughout the research process as part of the research team and advisory board. For this study, the advisory board has particularly contributed to the development process of the DESIRE intervention by actively participating in the four workshops, in the iterations between the workshops and in the preparation of the manuscript.

The impact of photobiomodulation on sleep and life quality in hemodialysis patients: A randomized controlled trial

The quality of life (QoL) and sleep quality are closely linked to the physical and psychological health of end-stage renal disease (ESRD) patients, especially those underwent hemodialysis (HD) therapy. This study aims to investigate the impact of 830 nm laser treatment on improving QoL and sleep quality in HD patients. Forty ESRD patients participated in this study. 830 nm laser was used to radiate on the palm (at dose of 256.10 J/cm2), ST 36 and KI 1 acupoints (at dose of 109.76 J/cm2) of HD patients, and QoL and sleep quality questionnaires were utilized to assess changes following the treatment. After 830 nm laser radiation, lower global Pittsburgh Sleep Quality Index and Athens Insomnia Scale scores were observed, accompanied by higher physical and mental component summary scores in MOS 36-item short-form health survey version 2 and a global World Health Organization Quality of Life Brief Version score. The laser group also showed significant improvements in QoL and sleep quality indicators. Additionally, pain levels decreased on the third day and after one month according to visual analogue scale. This study revealed the positive effects of 830 nm laser on palm, KI 1 and ST 36 acupoints for improving the QoL and sleep quality in ESRD patients underwent HD treatment. The results suggest that 830 nm laser applied to specific targets could be used as a complementary and alternative approach to increase the QoL and sleep quality in ESRD patients.

Hemodynamic and neuromuscular basis of reduced exercise capacity in patients with end-stage renal disease

PURPOSE

The present study aimed to characterize the exercise-induced neuromuscular fatigue and its possible links with cerebral and muscular oxygen supply and utilization to provide mechanistic insights into the reduced exercise capacity characterizing patients with end-stage renal disease (ESRD).

METHODS

Thirteen patients with ESRD and thirteen healthy males (CTR group) performed a constant-force sustained isometric contraction at 50% of their maximal voluntary isometric contraction (MVC) until exhaustion. Quadriceps muscle activation during exercise was estimated from vastus lateralis, vastus medialis, and rectus femoris EMG. Central and peripheral fatigue were quantified via changes in pre- to postexercise quadriceps voluntary activation (ΔVA) and quadriceps twitch force (ΔQtw,pot) evoked by supramaximal electrical stimulation, respectively. To assess cerebral and muscular oxygenation, throughout exercise, near-infrared spectroscopy allowed investigation of changes in oxyhemoglobin (∆O2Hb), deoxyhemoglobin (∆HHb), and total hemoglobin (∆THb) in the prefrontal cortex and in the vastus lateralis muscle.

RESULTS

ESRD patients demonstrated lower exercise time to exhaustion than that of CTR (88.8 ± 15.3 s and 119.9 ± 14.6 s, respectively, P < 0.01). Following the exercise, MVC, Qtw,pot, and VA reduction were similar between the groups (P > 0.05). There was no significant difference in muscle oxygenation (∆O2Hb) between the two groups (P > 0.05). Cerebral and muscular blood volume (∆THb) and oxygen extraction (∆HHb) were significantly blunted in the ESRD group (P < 0.05). A significant positive correlation was observed between time to exhaustion and cerebral blood volume (∆THb) in both groups (r2 = 0.64, P < 0.01).

CONCLUSIONS

These findings support cerebral hypoperfusion as a factor contributing to the reduction in exercise capacity characterizing ESRD patients.

Effects of Dietary Fiber Intake and the Prevalence of Constipation Among Patients With End-Stage Renal Disease (ESRD) in Jeddah, Saudi Arabia: A Cross-Sectional Observational Study

RATIONALE/BACKGROUND

Hemodialysis (HD) patients with end-stage renal disease (ESRD) are particularly prone to constipation, which has become a growing public health issue. Nutritional therapy, such as fiber intake, significantly influences the management of constipation. In Saudi Arabia, there is limited data on fiber consumption and its correlation with constipation management in HD patients.

AIMS

The study aimed to investigate the correlation between dietary fiber intake and its effect on the prevalence of constipation in HD patients.

MATERIALS AND METHODS

This cross-sectional observational study of 77 ESRD patients on HD aged 18+ was conducted in a single dialysis center over six months. A questionnaire was employed to diagnose constipation (as defined by the Rome IV criteria of constipation), and seven-day food records were used to evaluate dietary fiber intake.

RESULTS

A study found a high prevalence of constipation (53%) among participants, with a lower daily fiber intake than recommended. However, a significant relationship was found between fiber intake and constipation (p < 0.05) with lower fiber intake in constipated patients compared to non-constipated (p = 0.001).

CONCLUSION

The study highlights a significant link between fiber intake and constipation in HD patients, suggesting adequate daily intake of fiber was effective in preventing constipation and that nutritional counseling should include adequate daily fiber intake in medical therapy management.

Symptom profiles in patients receiving maintenance hemodialysis and their association with quality of life: a longitudinal study

PURPOSE

Many patients receiving maintenance hemodialysis experience one or multiple symptoms. Using a latent profile analysis to identify symptom profiles may provide insights for person-centered symptom management strategies.

METHODS

This is a longitudinal study based on data from patients receiving maintenance hemodialysis at three hospitals in Shanghai, China. Of the 448 patients who completed the surveys at baseline (T1), 309 completed the 12-month follow-up survey (T2). Symptoms and quality of life were measured by the Chinese version of Kidney Disease Quality of Life 36 Short Form. The optimal classification of symptoms was identified using latent profile analysis.

RESULTS

Five symptom profiles were identified: High (9.2%), Fatigue and Gastrointestinal (7.1%), Fatigue and Skin (10.7%), Skin (23.2%), and Low (49.8%). The high-symptom profile and the-fatigue-and-skin-symptom profile were associated with a lower level of physical functioning, a higher burden of kidney disease, and more negative effects of kidney disease than the low symptom profile at T1 and T2. Multivariate regression analysis showed that the high-symptom profile predicted a poorer physical functioning at T2, and the-fatigue-and-skin-symptom profile predicted a poorer physical functioning and higher burden of kidney disease at T2.

CONCLUSION

Patients receiving maintenance hemodialysis reported unique symptom experiences which could be classified into different profiles. Patients reporting an overall high level of symptoms or a high level of fatigue and skin symptoms were more likely to have a poorer quality of life.

The factors that are associated with itching in chronic kidney patients and evaluation of itching with the 5d itch scale

OBJECTIVE

Uremic pruritus is a distressing complication of chronic kidney disease (CKD), associated with mortality, and negatively impacts quality of life. The 5D-Itch Scale (5D-IS) is an easy-to-apply technique that evaluates 5 different dimensions of itching such as duration, severity, course, disability, and prevalence. We aimed to investigate the prevalence of itching in different CKD stages using the 5D-IS and to investigate the factors associated with itching in CKD patients.

MATERIALS AND METHODS

5D-IS was used to evaluate itching in chronic hemodialysis (HD) and Stage 3-5 CKD patients. Total itching score and sub-scores consist of duration, severity, course, disability and distribution were obtained. Itching scores and prevalence according to CKD stages were investigated. Also the relationships between itching scores and some laboratory and clinical parameters such as iPTH, Ca, P, CRP levels were examined.

RESULTS

158 CKD patients included in the study included (110 Stage 3-5 and 48 HD). The frequency of itching was higher in HD patients than in predialysis patients (62.5% vs 46.4%; p = 0.04). The total itching score increased along with CKD stages 3 to 5 (7.75 ± 3.39, 7.82 ± 4.11 and 9.08 ± 5.12 respectively; p = 0.14). The severity, duration and course scores of itching were similar between the groups, but the distribution scores increased as the CKD stage increased. The laboratory and clinical characteristics of patients with and without itching were not different. Even if a significant positive correlation was detected between the parathyroid hormone levels and both the total 5D-IS scores and all of the sub-scores, Ca and P values were not correlated with itching scores. In the multiple regression analysis, the only parameter that had an effect on the total 5D-IS Score was the parathyroid hormone level.

CONCLUSION

In CKD, itching affects 40-70% of patients from the early stages. As the CKD stage increases, itching spreads throughout the body. The only parameter that seems to be associated with itching is the PTH level.

Evaluation of a proteomic signature coupled with the kidney failure risk equation in predicting end stage kidney disease in a chronic kidney disease cohort

BACKGROUND

The early identification of patients at high-risk for end-stage renal disease (ESRD) is essential for providing optimal care and implementing targeted prevention strategies. While the Kidney Failure Risk Equation (KFRE) offers a more accurate prediction of ESRD risk compared to static eGFR-based thresholds, it does not provide insights into the patient-specific biological mechanisms that drive ESRD. This study focused on evaluating the effectiveness of KFRE in a UK-based advanced chronic kidney disease (CKD) cohort and investigating whether the integration of a proteomic signature could enhance 5-year ESRD prediction.

METHODS

Using the Salford Kidney Study biobank, a UK-based prospective cohort of over 3000 non-dialysis CKD patients, 433 patients met our inclusion criteria: a minimum of four eGFR measurements over a two-year period and a linear eGFR trajectory. Plasma samples were obtained and analysed for novel proteomic signals using SWATH-Mass-Spectrometry. The 4-variable UK-calibrated KFRE was calculated for each patient based on their baseline clinical characteristics. Boruta machine learning algorithm was used for the selection of proteins most contributing to differentiation between patient groups. Logistic regression was employed for estimation of ESRD prediction by (1) proteomic features; (2) KFRE; and (3) proteomic features alongside KFRE.

RESULTS

SWATH maps with 943 quantified proteins were generated and investigated in tandem with available clinical data to identify potential progression biomarkers. We identified a set of proteins (SPTA1, MYL6 and C6) that, when used alongside the 4-variable UK-KFRE, improved the prediction of 5-year risk of ESRD (AUC = 0.75 vs AUC = 0.70). Functional enrichment analysis revealed Rho GTPases and regulation of the actin cytoskeleton pathways to be statistically significant, inferring their role in kidney function and the pathogenesis of renal disease.

CONCLUSIONS

Proteins SPTA1, MYL6 and C6, when used alongside the 4-variable UK-KFRE achieve an improved performance when predicting a 5-year risk of ESRD. Specific pathways implicated in the pathogenesis of podocyte dysfunction were also identified, which could serve as potential therapeutic targets. The findings of our study carry implications for comprehending the involvement of the Rho family GTPases in the pathophysiology of kidney disease, advancing our understanding of the proteomic factors influencing susceptibility to renal damage.

Difference in functional connectivity between end-stage renal disease patients with and without restless legs syndrome: A prospective study

PURPOSE

The purpose of this study was to examine differences in functional connectivity between patients with end-stage renal disease (ESRD) with and without restless legs syndrome (RLS). In addition, the study aimed to identify any potential associations between RLS severity and functional connectivity.

METHODS

We enrolled patients with ESRD who had been undergoing hemodialysis. Patients with and without RLS were separated into two groups. Using functional near-infrared spectroscopy (fNIRS) and a graph theory approach, we determined the functional connectivity of patients with ESRD. The data were collected during a 300-s resting state evaluation performed in the dialysis room prior to dialysis.

RESULTS

Eighteen of 48 patients with ESRD were diagnosed with RLS, whereas 30 patients did not exhibit RLS symptoms. Notably, functional connectivity metrics differed significantly between patients with and without RLS. Specifically, patients with ESRD and RLS displayed higher values for mean clustering coefficient (0.474 vs. 0.352, p = 0.001), global efficiency (0.520 vs. 0.414, p = 0.001), strength (6.538 vs. 4.783, p = 0.001), and transitivity (0.714 vs. 0.521, p = 0.001), while values for diameter (5.451 vs. 7.338, p = 0.002), eccentricity (4.598 vs. 5.985, p = 0.004), and characteristic path length (2.520 vs. 3.271, p = 0.002) were lower in patients with ESRD and RLS compared to those without RLS. In addition, there were correlations between the RLS severity score and the assortative coefficient (r = 0.479, p = 0.044), the small-worldness index (r = -0.475, p = 0.046), and transitivity (r = 0.500, p = 0.034).

CONCLUSIONS

We demonstrated differences in functional connectivity between patients with ESRD with and without RLS, which may shed light on the pathophysiology of RLS. Notably, a number of functional connectivity metrics demonstrated strong associations with RLS severity. Our study also confirmed the applicability of fNIRS as a tool for investigating functional connectivity in patients with RLS.

Psychometrically validated questionnaires to measure the effects and benefits/barriers to physical exercise in hemodialysis patients: a systematic review

PURPOSE

To provide a critical assessment, summarize, and synthesize the evidence from studies using psychometrically validated questionnaires to assess the effects and benefits/barriers of physical exercise in hemodialysis patients.

METHODS

The search was performed on six electronic databases. It was conducted following the PRISMA statement and the PICO framework. The methodological quality was assessed using the MMAT. Were used the quality criteria for psychometric properties developed by Terwee et al.

RESULTS

Overall, 70 studies were included, and 39 questionnaires identified, evaluating 13 outcomes. The quality of the psychometric properties of the questionnaires was not always described; only 13 presented positive ratings on > =6/9 properties. The most assessed measure was criterion validity, and the least assessed criteria was responsiveness. The most outcome measured by these questionnaires was quality of life using SF-36, followed by psychological health using the BDI. The DPEBBS was the only instrument identified that assessed the benefits and barriers of exercise.

CONCLUSION

Quality of life and depression were the most frequent outcomes. Other measures contemplating physical, mental, cognitive performance, and especially of the perceptions benefits and barriers to exercise should be further investigated. We have clearly identified the need for more studies evaluating psychometric measures that have not been tested satisfactorily or hardly been tested at all.

Establishing the Kidney dIsease in the National guarD (KIND) registry: an opportunity for epidemiological and clinical research in Saudi Arabia

BACKGROUND

In Saudi Arabia (SA), there has been an alarming increase in the prevalence of chronic kidney diseases (CKD) over the last three decades. Despite being one of the largest countries in the Middle East, renal conditions remain understudied, and there is limited data on their epidemiology and outcomes in SA.

OBJECTIVES

To document the experience of establishing a local renal registry assessing the epidemiology of CKD and identifying potential areas for improving the quality and delivery of care for CKD patients.

METHODS

This is a multi-center retrospective registry. Potential participants were identified through the ICD-10 codes from five hospitals serving the National Guard affiliates in SA. Patients aged ≥ 18 years treated in any National Guard hospital since 2010 for glomerulonephritis, CKD, or received hemodialysis, peritoneal dialysis, or renal transplant were enrolled. Once enrolled in the registry, patients were followed to the last visit date. RedCap was used to create and host the online registry platform.

RESULTS

A total of 2,912 patients were included, and more than half were younger than 60 years old. Two-thirds of the patients were overweight (25%) or obese (37%). Glomerulonephritis was diagnosed in 10% of the patients, and dialysis-dependent and kidney transplant patients accounted for 31.4% and 24.4%, respectively. Hypertension and diabetes mellitus were detected among 52% and 43% of the participants, respectively. Hemodialysis was the most prevalent dialysis method, with patients spending 3.6 ± 0.4 h per session to receive this treatment. One in every five participants had a kidney biopsy taken (21%). Several barriers and facilitators of the success of this registry were identified.

CONCLUSIONS

The KIND registry provides much-needed information about CKD in Saudi Arabia and serves as a model for future projects investigating the natural history and progression of the spectrum of renal diseases. Logistic and financial challenges to the sustainability of registries are identified and discussed.

Cross-cultural validation of the Portuguese version of the Dialysis Symptom Index for haemodialysis patients

Background

Patients with end-stage renal disease (ESRD) undergoing haemodialysis (HD) are associated with low quality of life (QoL) and high disease-related symptoms. The patient self-report instruments can assess the burden of physical and psychological symptoms. The Dialysis Symptom Index (DSI) is a specific instrument to evaluate the multidimensional reported symptoms by patients undergoing HD.

Aims

To translate, validate and assess the psychometric properties of the Portuguese version of the DSI.

Methods

A cross-cultural adaptation process from English to Portuguese and a validation study (n = 156) were conducted. Reliability, validity and responsiveness were assessed.

Results

The patients' most reported symptoms were, nausea (n = 86, 55%), muscle cramps (n = 92, 59%), feeling tired or lack of energy (n = 92, 59%), bone or joint pain (n = 88, 56%) and trouble staying asleep (n = 95, 60%). Cronbach's alpha of the DSI was 0.87, and intraclass correlation coefficient was 0.868 (95%CI 0.836-0.896). The smallest detectable change was 28.32.

Conclusion

The Portuguese DSI demonstrates excellent psychometric properties for assessing HD patients' reported symptoms. It highlights symptom severity and impact, providing valuable insights for healthcare practitioners. Nurses can use the DSI to tailor interventions and enhance patient-centred care.

Pain and quality of life of patients with end-stage renal disease undergoing hemodialysis in Aseer region, Saudi Arabia

BACKGROUND

Pain has an adverse effect on HRQoL and has social, psychological, and physical repercussions for ESRD patients. In the present study, we assessed chronic pain in ESRD patients on HD in terms of severity and interference with activity. We also assessed the impact it has on these patients, along with looking at the factors that were linked to QoL in this population.

METHODS

A multicenter, cross-sectional study carried out between April and July of 2023 in the hemodialysis units of Asir Central Hospital and Khamis Mushait General Hospital. Brief Pain Inventory and European Quality of Life scale 5 dimensions (EQ-5D) scale, including its European Quality of Life visual analogue scale (EQ-VAS) component, were used to assess pain and QoL, respectively.

RESULTS

A total of 97 participants were included in the final study. The average interference level of pain with daily functions was 22.5 ± 15.0 out of 70. The mean interference score was significantly higher among patients at rural areas (28.2 ± 16.3; P = 0.012), and those who undergone dialysis session for ≥ 4 times per week (31.6 ± 16.7; P = 0.026). The overall score of quality of life ranged from 20% to 92% with mean score of 36.5 ± 12.8%. The multiple linear regression analysis revealed that patients with higher BMI, more frequent dialysis sessions per week, and higher level of pain interference with daily functions demonstrated lower QoL (B= - 2.36, - 1.46, and - 0.64, respectively.

CONCLUSIONS

Pain has a significant negative impact on QoL in ESRD patients undergoing HD. Patients with higher BMI, more frequent dialysis sessions, and higher level of pain interference with daily functions are at higher risk of lower QoL. These findings provide valuable information for educators, physicians, and other healthcare providers working with patients undergoing HD.

Actioning the findings of hard endpoint clinical trials as they emerge in the realm of chronic kidney disease care: a review and a call to action

Fewer than half of patients treated with hemodialysis survive 5 years. Multiple therapeutics are used to address the complications of advanced chronic kidney disease but most have not been found to improve clinical outcomes. Clinical trials of treatment innovations for chronic kidney diseases and dialysis care have been suboptimal in number and quality. Recent trials are changing this trend. Practice and policy change when new evidence emerges remains frequently impeded by resource and organizational constraints and accordingly, clinical practice guidelines are updated years or decades after definitive evidence is produced. Ultimately, practice change in health systems is slow, leading to impaired uptake of effective medical interventions and lower value healthcare, although innovations in rapid guideline production are emerging. What can be done to ensure that conclusive evidence is taken up in practice, policy and healthcare funding? We use the example of the recently published hard endpoint study "Comparison of high-dose HDF with high-flux HD" (CONVINCE) (hemodiafiltration versus hemodialysis), to explain how a new trial can impact on medical knowledge and change in practices. We (i) assess how the trial can be placed in the context of the totality of the evidence, (ii) define whether or not further trials of convective dialysis therapies are still needed and (iii) examine whether the evidence for convective therapies is now ready to inform practice, policy and funding change. When looking at CONVINCE in the context of the totality of evidence, we show that it addresses dialysis quality improvement priorities and is consistent with other trials evaluating convective dialysis therapies, and that the evidence for convective dialysis therapies is now definitive. Once updated evidence for cost-effectiveness in specific healthcare settings and patient-reported outcomes become available, we should therefore determine whether or not clinical practice guidelines should recommend uptake of convective dialysis therapies routinely, and move on to evaluating other treatments.

Common and distinct risk factors that influence more severe and distressing shortness of breath profiles in oncology outpatients

BACKGROUND

Shortness of breath occurs in 10%-70% of oncology patients. Very little is known about interindividual variability in its severity and distress and associated risk factors. Using latent profile analyses (LPAs), purpose was to identify subgroups of patients with distinct severity and distress profiles for shortness of breath as single symptom dimensions. In addition, a joint LPA was done using patients' severity AND distress ratings. For each of the three LPAs, differences among the shortness of breath classes in demographic, clinical, symptom, stress, and resilience characteristics were evaluated.

METHODS

Patients completed ratings of severity and distress from shortness of breath a total of six times over two cycles of chemotherapy. All of the other measures were completed at enrollment (i.e., prior to the second or third cycle of chemotherapy). Separate LPAs were done using ratings of severity and distress, as well as a joint analysis using severity AND distress ratings. Differences among the latent classes were evaluated using parametric and nonparametric tests.

RESULTS

For severity, two classes were identified (Slight to Moderate [91.6%] and Moderate to Severe [8.4%]). For distress, two classes were identified (A Little Bit to Somewhat [83.9%] and Somewhat to Quite a Bit [16.1%]). For the joint LPA, two classes were identified (Lower Severity and Distress [79.9%] and Higher Severity and Distress [20.1%]). While distinct risk factors were associated with each of the LPAs, across the three LPAs, the common risk factors associated with membership in the worse class included: a past or current history of smoking, poorer functional status, and higher comorbidity burden. In addition, these patients had a higher symptom burden and higher levels of cancer-specific stress.

CONCLUSIONS

Clinicians can use the information provided in this study to identify high-risk patients and develop individualized interventions.

Chronic kidney disease may evoke anxiety by altering CRH expression in the amygdala and tryptophan metabolism in rats

Chronic kidney disease (CKD) is associated with anxiety; however, its exact mechanism is not well understood. Therefore, the aim of the present study was to assess the effect of moderate CKD on anxiety in rats. 5/6 nephrectomy was performed in male Wistar rats. 7 weeks after, anxiety-like behavior was assessed by elevated plus maze (EPM), open field (OF), and marble burying (MB) tests. At weeks 8 and 9, urinalysis was performed, and blood and amygdala samples were collected, respectively. In the amygdala, the gene expression of Avp and the gene and protein expression of Crh, Crhr1, and Crhr2 were analyzed. Furthermore, the plasma concentration of corticosterone, uremic toxins, and tryptophan metabolites was measured by UHPLC-MS/MS. Laboratory tests confirmed the development of CKD. In the CKD group, the closed arm time increased; the central time and the total number of entries decreased in the EPM. There was a reduction in rearing, central distance and time in the OF, and fewer interactions with marbles were detected during MB. CKD evoked an upregulation of gene expression of Crh, Crhr1, and Crhr2, but not Avp, in the amygdala. However, there was no alteration in protein expression. In the CKD group, plasma concentrations of p-cresyl-sulfate, indoxyl-sulfate, kynurenine, kynurenic acid, 3-hydroxykynurenine, anthranilic acid, xanthurenic acid, 5-hydroxyindoleacetic acid, picolinic acid, and quinolinic acid increased. However, the levels of tryptophan, tryptamine, 5-hydroxytryptophan, serotonin, and tyrosine decreased. In conclusion, moderate CKD evoked anxiety-like behavior that might be mediated by the accumulation of uremic toxins and metabolites of the kynurenine pathway, but the contribution of the amygdalar CRH system to the development of anxiety seems to be negligible at this stage.

Examining the acceptability and feasibility of the Compassionate Mindful Resilience (CMR) programme in adults living with chronic kidney disease: the COSMIC study findings

BACKGROUND

Individuals with chronic kidney disease experience difficult physical and psychological symptoms, that impact quality of life, and are at increased risk of anxiety and depression. Access to specialist psychological support is limited. This study aimed to support a new service development project, in collaboration with Kidney Care UK, to implement the Compassionate Mindful Resilience (CMR) programme, developed by MindfulnessUK, which provides accessible mindfulness techniques and practices to enhance compassion and resilience, and explore its feasibility for people living with stage 4 or 5 kidney disease and transplant.

METHODS

A multi-method feasibility design was utilised. Participants over 18 years, from the UK, with stage 4 or 5 kidney disease or post-transplant, and who were not currently undergoing psychotherapy, were recruited to the four-week CMR programme. Data was collected at baseline, post-intervention and three-months post to measure anxiety, depression, self-compassion, mental wellbeing, resilience, and mindfulness. The acceptability of the intervention for a kidney disease population was explored through qualitative interviews with participants, and the Mindfulness Teacher.

RESULTS

In total, 75 participants were recruited to the study, with 65 completing the CMR programme. The majority were female (66.2%) and post-transplant (63.1%). Analysis of completed outcome measures at baseline and post-intervention timepoints (n = 61), and three-months post intervention (n = 45) revealed significant improvements in participant's levels of anxiety (p < .001) and depression (p < .001), self-compassion (p = .005), mental wellbeing (p < .001), resilience (p.001), and mindfulness (p < .001). Thematic analysis of interviews with participants (n = 19) and Mindfulness Teacher (n = 1) generated three themes (and nine-subthemes); experiences of the CMR programme that facilitated subjective benefit, participants lived and shared experiences, and practicalities of programme participation. All participants interviewed reported that they found programme participation to be beneficial.

CONCLUSION

The findings suggest that the CMR programme has the potential to improve psychological outcomes among people with chronic kidney disease. Future randomized controlled trials are required to further test its effectiveness.