Establishing Core Outcome Domains in Hemodialysis: Report of the Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) Consensus Workshop

End-stage kidney diseases in areas of conflict: patients' perspective and patient access to hemodialysis services in Northwest Syria

BACKGROUND

There are an estimated 850 persons with End-Stage Kidney Disease (ESKD) receiving hemodialysis in the conflict-affected Northwest Syria. This study examines patients' perspectives, and experiences with hemodialysis and their knowledge about their disease and treatment.

METHODS

This study used telephone interviews with 101 randomly selected ESKD patients from 12 of the 14 hemodialysis units in Northwest Syria during early 2023 in a cross-sectional study.

RESULTS

The mean age of respondents was 50.3 ± 16.7 years (range 7 to 81), with 55.4% males. The sample included 53 local residents and 48 Internally Displaced Persons (IDPs) from elsewhere in Syria. A quarter (28.7%) of patients reported being unable to access one or more hemodialysis sessions in the previous year. In the past year, 61 of 101 dialysis patients had changed household location because of reported insecurity. Frequent household relocations disrupted dialysis continuity resulting in the use of multiple dialysis sites. Because of the decentralized distribution of facilities, half of patients could reach their dialysis facility in 30 min or less, and at minimal costs. Two-thirds (67.3%) reported the presence of comorbidities, with hypertension and diabetes being the most common. Of the 35 patients with diabetes, 15 required insulin. Only about half (52.5%) had seen a nephrologist or physician in the past six months. The health literacy level concerning ESKD, and hemodialysis was low for many patients.

CONCLUSION

While considerable resilience is seen among hemodialysis patients in conflict areas of Northwest Syria, there are deficits in care and health literacy concerning ESKD and hemodialysis which should be addressed. There are a number of low resource actions which could be undertaken for this population to improve their health and understanding of their disease which are currently being considered.

Development, Rasch analysis and validation of the kidney symptom burden questionnaire (KSB-Q)

Background

Increasingly, patient-reported outcome measures (PROMs) are used to monitor chronic kidney disease (CKD) symptoms in routine clinical practice. However, such symptom measurement currently requires completion of multiple, often lengthy, PROMs, which may lead to questionnaire fatigue, lower levels of completion, and missing data. Moreover, many CKD-specific PROMs lack evidence of important measurement properties and few were developed using contemporary psychometric methods. The study objective was to develop and validate a short-form kidney symptom burden questionnaire (KSB-Q).

Methods

A cross-sectional item pool survey was distributed to adults (≥18 years) with CKD stages 3-5 [including individuals not receiving kidney replacement therapy (KRT), those receiving dialysis and those with a functioning kidney transplant] in England (Birmingham, London, Sheffield, and Nottingham) from March to September 2022. Rasch measurement was used to assess the psychometric properties of the item pool. Cognitive debriefing interviews were conducted to evaluate content validity.

Results

In total, 419/1464 participants responded (29% response rate), with 28% receiving dialysis and 30% in receipt of a kidney transplant. Rasch analysis indicated that nine items, one for each of nine symptom domains (fatigue, pain, memory/concentration, poor sleep, skin problems, gastrointestinal problems, dizziness, restless legs, and shortness of breath), formed a PROM with strong psychometric properties (including statistically acceptable reliability, test-retest reliability, and validity). Cognitive debriefing and survey responses confirmed content validity encompassing relevance, comprehensiveness, and clarity.

Conclusions

The KSB-Q is a nine-item PROM measuring somatic symptoms. The KSB-Q demonstrates strong psychometric properties in patients with CKD stages 3-5, including those not receiving KRT, individuals receiving dialysis, and those with a functioning kidney transplant.

Effect of pharmacist interventions in chronic kidney disease: a meta-analysis

BACKGROUND

Pharmacists are uniquely placed with their therapeutic knowledge to manage people with chronic kidney disease (CKD). Data are limited regarding the impact of pharmacist interventions on economic, clinical and humanistic outcomes (ECHO).

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) of interventions with pharmacist input was conducted, which included adults with a diagnosis of CKD, including those with and without kidney replacement therapy. Data were extracted on ECHO: economic (e.g. healthcare-associated costs), clinical (e.g. mortality) and humanistic (e.g. patient satisfaction) outcomes. Where appropriate, a random-effects model meta-analysis generated a pooled estimate of effect. A direction of effect plot was used to summarize the overall effects for clinical outcome domains.

RESULTS

Thirty-two RCTs reported a total of 10 economic, 211 clinical and 18 humanistic outcomes. Pharmacist interventions resulted in statistically significant improvements in systolic blood pressure and hemoglobin levels, but not in diastolic blood pressure, estimated glomerular filtration rate, creatinine and low-density lipoprotein cholesterol levels. Mixed findings were reported for clinical and economic outcomes, whilst pharmacist interventions resulted in an improvement in humanistic outcomes such as patient satisfaction and patient knowledge.

CONCLUSION

Findings showed pharmacist interventions had mixed results for various outcomes. Future studies should be more robustly designed and take into consideration the role of the pharmacist in prescribing and deprescribing, the findings of which will help inform research and clinical practice.

TRIAL REGISTRATION

The review was prospectively registered on PROSPERO (CRD42022304902).

Mapping the Kidney Disease Quality-of-Life Questionnaire Onto the EQ-5D-5L Utility Index in Patients Undergoing Hemodialysis

OBJECTIVES

Although widely used as a tool to measure quality of life, the Kidney Disease Quality-of-Life Questionnaire (KDQoL-36) does not include a measure of health utility that would enable economic analyses to be performed. This study aimed to map the KDQoL-36 onto the EQ-5D-5L utility index for patients with end-stage kidney disease undergoing hemodialysis.

METHODS

For the development of the mapping function, data from a randomized controlled trial in the United Kingdom were used and consisted of 6603 observations. Two modeling techniques were applied: (1) linear regression with fixed effects and (2) adjusted limited dependent variable mixture model (ALDVMM). Several model specifications were tested, and the preferred model was chosen based on a catalog of performance indicators. The validation phase involved applying a selection of the top-performing models to an independent UK data set consisting of 117 observations.

RESULTS

The ALDVMM model with 3 components, using 5 domains; physical component score, mental component score, burden, symptoms, and effects, as well as age and sex as explanatory variables, was the preferred model during the estimation phase. The validation phase supported this result because the 3 component ALDVMM was the highest performing model. This model dominated in all aspects of predictive performance.

CONCLUSIONS

This novel mapping function translates the KDQoL-36 to EQ-5D-5L values in patients with end-stage kidney disease undergoing hemodialysis, using data from the United Kingdom. They demonstrate satisfactory fit and precision, providing valuable tools for clinicians and researchers, particularly in situations in which generic preference-based health-related quality-of-life instruments are inaccessible for utility derivation in cost-effectiveness studies.

Geriatric Assessment in Older Patients with Advanced Kidney Disease: A Key to Personalized Care and Shared Decision-Making-A Narrative Review

As the global population ages, so too does the prevalence of older people with chronic kidney disease (CKD). Helping people age well with CKD and supporting older people with end-stage kidney disease (ESKD) to make personalized decisions regarding kidney replacement therapy (KRT) or conservative care (CC) are an essential component of care. However, these factors are relatively underreported in both the fields of nephrology and geriatric medicine, and prospective, randomized evidence is lacking. This narrative review article, authored by both nephrologists and geriatricians, discusses specific geriatric issues that arise in older people with CKD and why they matter. The available evidence for KRT or CC in older people with frailty is outlined. The importance of performing a comprehensive geriatric assessment, or a modified nephrogeriatric assessment, to ensure a systematic evaluation of the person's medical problems and life needs, goals, and values is described. We consider different models of nephrogeriatric care and how they may be implemented. Kidney supportive care-addressing an individual's symptoms and overall well-being alongside the more traditional nephrological principles of preventing disease progression and optimizing risk-is highlighted throughout the article. We outline ways of identifying the later stages of a person's disease journey, when transition to palliative care is indicated, and elaborate methods of preparing patients for this through multidisciplinary advance care planning. Finally, we discuss practice and systems for nephrogeriatric care in five different European countries and consider future directions, challenges, and highlights in this rapidly evolving, increasingly relevant field.

Establishing Research Priorities in Geriatric Nephrology: A Delphi Study of Clinicians and Researchers

RATIONALE & OBJECTIVE

Despite substantial growth of the population of older adults with kidney disease, there remains a lack of evidence to guide clinical care for this group. The Kidney Disease and Aging Research Collaborative conducted a Delphi study to build consensus on research priorities for clinical geriatric nephrology.

STUDY DESIGN

Asynchronous modified Delphi study.

SETTING & PARTICIPANTS

Clinicians and researchers in the United States and Canada with clinical experience and/or research expertise in geriatric nephrology.

OUTCOME

Research priorities in geriatric nephrology.

ANALYTICAL APPROACH

In the first Delphi round, participants submitted free-text descriptions of research priorities considered important for improving the clinical care of older adults with kidney disease. Delphi moderators used inductive content analysis to group concepts into categories. In the second and third rounds, participants iteratively reviewed topics, selected their top 5 priorities, and offered comments used to revise categories.

RESULTS

Among 121 who were invited, 57 participants (47%) completed the first Delphi round and 48 (84% of enrolled participants) completed all rounds. After 3 rounds, the 5 priorities with the highest proportion of agreement were (1) communication and decision-making about treatment options for older adults with kidney failure (69% agreement), (2) quality of life, symptom management, and palliative care (67%), (3) frailty and physical function (54%), (4) tailoring therapies for kidney disease to specific needs of older adults (42%), and (5) caregiver and social support (35%). Health equity and person-centricity were identified as cross-cutting features that informed all topics.

LIMITATIONS

Relatively low response rate and limited participation by private practitioners and older clinicians and researchers.

CONCLUSIONS

Experts in geriatric nephrology identified clinical research priorities with the greatest potential to improve care for older adults with kidney disease. These findings provide a road map for the geriatric nephrology community to harmonize and maximize the impact of research efforts.

Early Versus Late Initiation of Dialysis in CKD Stage 5: Time for a Consensus

Chronic kidney disease (CKD), a major global public health problem, emerged as one of the leading causes of death, affecting over 800 million individuals worldwide, with significant burden to patients and their caregivers, and may lead to end-stage kidney disease (ESKD). The decision on optimal initiation of chronic dialysis is a common problem faced by nephrologists, patients, and caregivers due to lack of adequate data. Determining the ideal time to initiate maintenance dialysis for individuals struggling with ESKD has remained a puzzle. Currently, there is no consensus among guidelines as to the best time to initiate dialysis. Discrepancies in guidelines stem from lack of adequate data, necessitating larger randomized controlled trials to fill this major gap and come to a universal acceptance by the nephrology community about the optimal time to initiate dialysis for patients with advanced CKD. The fact that there has been only 1 randomized controlled trial that addressed early versus late dialysis initiation is inadequate to convincingly answer such as critical clinical decision making. In this review, we analyze the available literature and try to come up with recommendations for further studies to guide nephrologists about the best time to initiate dialysis for patients approaching ESKD.

Care for end-stage kidney disease in China: progress, challenges, and recommendations

This review comprehensively evaluates China's progress in care of end-stage kidney disease (ESKD) by identifying achievements and gaps, reviewing ESKD-related policy initiatives, and proposing policy recommendations. In the past decade, China has made laudable progress in access to ESKD care with narrowed difference between the number of patients needing and receiving kidney replacement therapies (KRT). China has also experienced significant improvements in clinical quality and outcomes of ESKD care. These achievements stem from concerted efforts in advocating effective policies, increasing fiscal subsidies, re-designing health insurance schemes, encouraging healthcare delivery from both public and private sectors, and improving quality regulation. However, challenges remain, including inequitable access to care across regions and groups, and suboptimal quality and outcomes in some underdeveloped areas. To address these gaps, we recommend reforming the financing policy, adopting quality-based payment methods, strengthening quality monitoring system, improving chronic kidney disease prevention and management, and developing alternative KRT modalities.

The RADAR technique in reconstruction of failed autologous arteriovenous fistulas due to juxta-anastomotic stenosis is equivalent to that with traditional surgery in maintenance hemodialysis patients

OBJECTIVE

Autologous arteriovenous fistula (AVF) is recommended as superior vascular access for hemodialysis but has a high rate of failure, and juxta-anastomotic stenosis (JAS) is one of the predominant causes of fistula failure. The aim of this study was to compare the primary patency in reconstruction of failed AVFs due to JAS between the radial artery deviation and reimplantation (RADAR) technique and traditional surgery (end-vein to side-artery neo-anastomosis) in maintenance hemodialysis (MHD) patients.

METHODS

A total of 1215 MHD patients with failed AVF were enrolled in this retrospective cohort study, and 614 patients with failed AVF received surgical intervention. Among these surgical interventions, 417 patients experienced AVF failure due to JAS. Finally, 25 patients who received the RADAR technique were enrolled. Controls of 50 patients received traditional surgery were randomly selected matched by age and sex. Clinical data such as age, sex, comorbidities, and blood biochemical indices were collected. Kaplan-Meier survival curves and Cox proportional hazards analyses were used to explore the difference between the RADAR group and the traditional group in reconstruction of failed AVFs.

RESULTS

The RADAR group and the traditional group shared common baseline characteristics. The primary patencies of the reconstructed AVFs were 88.8%, 79.0%, 72.2%, 57.4%, and 38.3% at 12, 24, 36, 48, and 60 months among the 75 patients, respectively. Kaplan-Meier survival curve analysis demonstrated similar primary patencies in the two groups (log-rank test, p = 0.73). Compared with the traditional group, the RADAR group had no difference in predicting AVF failure after adjusting for potential confounders, with an HR of 0.92 (95% CI, 0.18-4.63).

CONCLUSIONS

The primary patency of the RADAR technique and the traditional surgery in the reconstruction of failed AVFs due to JAS is almost equal in 5 years.

Review of the target trial methodological approach on treatment effect estimates in kidney failure: protocol for a systematic assessment

BACKGROUND

Patients with kidney failure often lack robust evidence because they are excluded from randomized trials. Trial emulation provides an alternative approach to derive treatment effect estimates when randomized trials cannot be conducted. Critical questions about the comparative efficacy and safety of interventions in kidney failure are now being answered using this approach or parts of it. However, variations and inconsistencies in reporting cast doubt on the reliability and validity of effect estimates not derived from randomized trials. The aim of this methodological systematic review is to understand the extent to which the target study approach is used in kidney failure and the appropriateness of this approach. By identifying and evaluating studies that qualify as emulating a target trial, compared with studies that did not apply the principles. We aim to provide more specific methodological guidance to increase the clarity and reliability of reporting treatment effect estimates when running a trial in kidney failure is not feasible.

METHODS

This protocol is developed in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses Protocols (PRISMA-P) statement. MEDLINE, Embase, and reference lists (backwards citation chasing) will be searched up until 1st July 2023 and the search updated prior to publication to identify all studies evaluating patient outcomes in late-stage kidney disease and failure that use target trial emulation as the primary approach for analysis. Two authors (A. A., P. K.) will select articles based on title and abstract and then full text, with a third reviewer settling disagreements (J. P.). The prespecified variables will be extracted, and the risk of bias will be assessed by at least two authors (A. A., P. K., A. N.) using prespecified data forms. This will enable the determination of the robustness of the methodological quality of observational studies in using the whole or elements of the target trial approach. We will thereby assess their ability to reliably report treatment effect estimates.

DISCUSSION

We will provide specific methodological recommendations on how to design target trials and model assumptions for emulation to get reliable treatment effect estimates for therapeutic interventions in kidney failure.

METHODOLOGICAL SYSTEMATIC REVIEW REGISTRATION

Open Science Framework: Identifier https://doi.org/10.17605/OSF.IO/Z4Y29 .

The CONVINCE randomized trial found positive effects on quality of life for patients with chronic kidney disease treated with hemodiafiltration

In the CONVINCE trial, the primary analysis demonstrated a survival benefit for patients receiving high-dose hemodiafiltration (HDF) as compared with high-flux hemodialysis (HD). A secondary objective was to evaluate effects on health-related quality of life (HRQoL); assessed in eight domains (physical function, cognitive function, fatigue, sleep disturbance, anxiety, depression, pain interference, social participation) applying instruments from the Patient-Reported Outcome Measurement Information System (PROMIS) before randomization and every three months thereafter. In total 1360 adults with dialysis-dependent chronic kidney disease, eligible to receive high-flux HDF (23 liters or more), were randomized (1:1); 84% response rate to all questionnaires. Both groups reported a continuous deterioration in all HRQoL domains. Overall, raw score changes from baseline were more favorable in the HDF group, resulting in a significant omnibus test after a median observation period of 30 months. Most relevant single raw score differences were reported for cognitive function. Patients receiving HDF reported a decline of -0.95 units (95% confidence interval - 2.23 to +0.34) whereas HD treated patients declined by -3.90 units (-5.28 to - 2.52). A joint model, adjusted for mortality differences, utilizing all quarterly assessments, identified a significantly slower HRQoL decline in physical function, cognitive function, pain interference, and social participation for the HDF group. Their physical health summary score declined -0.46 units/year slower compared to the HD group. Thus, the CONVINCE trial showed a beneficial effect of high-dose hemodiafiltration for survival as well as a moderate positive effect on patients' quality of life, most pronounced with respect to their cognitive function. REGISTRATION: NTR7138 on the International Clinical Trials Registry Platform.

Experiences of Social Isolation and Loneliness in Chronic Kidney Disease: A Secondary Qualitative Analysis

Key Points

Loneliness and social isolation are increasingly recognized as global public health issues; however, little is known about the patient and caregiver experience in CKD. We used qualitative data to explore the experiences of loneliness and social isolation from the perspective of patients and caregivers.

Background

Many patients with CKD experience loneliness and social isolation, which are associated with a higher risk of mortality, morbidity, and poor mental health. We aimed to describe the perspectives of patients with CKD and their caregivers on loneliness and social isolation, to inform strategies to increase social participation.

Methods

A secondary analysis of qualitative data from the Standardized Outcomes in Nephrology initiative dataset (36 focus groups, three Delphi surveys, and seven consensus workshops) was conducted. We extracted and thematically analyzed data from patients with CKD, including those receiving hemodialysis or peritoneal dialysis and those with a kidney transplant, as well as their caregivers, on the perspectives and experiences of loneliness and social isolation.

Results

Collectively, the studies included 1261 patients and caregivers from 25 countries. Six themes were identified: restricted by the burdens of disease and treatment (withdrawing from social activities because of fatigue, consumed by the dialysis regimen, tethered to treatment, travel restrictions); external vulnerability (infection risk, anxiety of dining out); diminishing societal role (grieving loss of opportunities, social consequences of inability to work); fending for oneself in health care (no one to relate to, lost in uncertainty, unmet psychosocial needs); undermining self-esteem (unable to engage in activities which previously defined self, shame and self-consciousness about appearance, hindering confidence for intimate relationships); and feeling ostracized (disconnected by family and friends, fear of stigma and being misunderstood, guilt of burdening others).

Conclusions

For patients with CKD and their caregivers, social participation is substantially impaired by the burden of CKD and its treatment and fear of risks to health such as infection. This undermines patient and caregiver mental health, particularly self-esteem and sense of belonging. Additional interventions are needed to improve social connections among people with CKD and their caregivers.

Impact of arteriovenous fistula aneurysms on a UK dialysis populations' perception of vascular access

BACKGROUND

Clinically-oriented outcome measures are increasingly being recognized as lacking in consideration of factors important to patients. There is an emerging move of guideline bodies advocating a more patient-centred approach. Aneurysms in autogenous arteriovenous fistula (AVF) can be considered unsightly and a constant reminder for patients of their dependence on dialysis. However, their impact on patient's perception has not previously been reported.

METHODS

Between April 2017-18, the Vascular Access Questionnaire (VAQ) was administered to prevalent haemodialysis patients across ten dialysis units via structured interviews, as part of a quality improvement project. Data for the subgroup of patients with aneurysmal AVF (categorised as per classification by Valenti et al.), were retrospectively evaluated and compared to the wider cohort.

RESULTS

Data were collected for 539 patients (median age: 66 years; 59% male), of whom 195 (36%) had aneurysmal AVF, with Type 2 morphology (cannulation site) being the most common (75%). Duration of AVF was found to be significantly associated with aneurysmal development, with estimated likelihoods of 11%, 43% and 61% after one, five and ten years, respectively. Interestingly, patients with diabetes had a significantly lower prevalence of aneurysmal development than those that were non-diabetic (25% vs. 43%, p < 0.001). Overall VAQ scores were not found to differ significantly by aneurysm status (p = 0.816) or across morphology types (p = 0.277). However, patients with aneurysmal AVF were significantly more concerned with the appearance of their AVF (p < 0.001) than the wider cohort. Despite this, patients with aneurysmal AVF gave significantly higher scores for satisfaction and ease of use and lower scores for bruising and clotting (p < 0.05).

CONCLUSIONS

Aneurysmal AVF are often cited as an important factor by patients for not proceeding with fistula formation. In this evaluation of patient reported experiences, those with aneurysmal AVF reported high satisfaction levels. This may help clinicians highlight positive patient reported outcomes of aneurysmal AVF during preprocedural consent processes.

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.

Global data monitoring systems and early identification for kidney diseases

BACKGROUND

Data monitoring and surveillance systems are the cornerstone for governance and regulation, planning, and policy development for chronic disease care. Our study aims to evaluate health systems capacity for data monitoring and surveillance for kidney care.

METHODS

We leveraged data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA), an international survey of stakeholders (clinicians, policymakers and patient advocates) from 167 countries conducted between July and September 2022. ISN-GKHA contains data on availability and types of kidney registries, the spectrum of their coverage, as well as data on national policies for kidney disease identification.

RESULTS

Overall, 167 countries responded to the survey, representing 97.4% of the global population. Information systems in forms of registries for dialysis care were available in 63% (n = 102/162) of countries, followed by kidney transplant registries (58%; n = 94/162), and registries for non-dialysis chronic kidney disease (19%; n = 31/162) and acute kidney injury (9%; n = 14/162). Participation in dialysis registries was mandatory in 57% (n = 58) of countries; however, in more than half of countries in Africa (58%; n = 7), Eastern and Central Europe (67%; n = 10), and South Asia (100%; n = 2), participation was voluntary. The least-reported performance measures in dialysis registries were hospitalization (36%; n = 37) and quality of life (24%; n = 24).

CONCLUSIONS

The variability of health information systems and early identification systems for kidney disease across countries and world regions warrants a global framework for prioritizing the development of these systems.

Exercise, Dialysis, and Environment: A Narrative Review in an Ecological Perspective

BACKGROUND

Patient empowerment and environmental sustainability may contribute to creating efficient and resilient healthcare models. Chronic kidney diseases call for a sustainable approach aimed at improving physical function and mental health of patients and possibly contributing to the slowing down of the evolution toward the end stage of renal disease (ESRD) with a reduction of the environmental and economic impact.

SUMMARY

Multidisciplinary interventions should be implemented particularly, at the final stages when patients are exposed to sedentariness, reduced health-related quality of life (HR-QoL), high cardiovascular morbidity and mortality, and the healthcare services to high costs, and participation in environmental pollution. Ecological strategies based on specific nutritional approaches, exercise, and environment should be designed and tested. In particular, the introduction to physical exercise represents a useful replacement therapy to counteract the hazards derived from the sedentary behavior of ESRD patients, with low physical function associated with poor clinical outcomes. A more active and healthy lifestyle, particularly in the natural environment, could impact HR-QoL, mental and physical well-being but also on socialization, with lower anxiety and fatigue stress levels. Otherwise, combining sustainable exercise models into the patient's daily routine can be enhanced by the biophilic design called to reproduce a natural environment in the dialysis center. Finally, the involvement of the personnel and the health professionals in properly managing the exercise interventions and the related factors (location, modality, dose, intensity, and duration) might improve the patients' participation. In particular, ecological programs should be broadly inclusive and aimed to target the lowest performing populations through minimal feasible doses of exercise.

KEY MESSAGES

Moving toward an ecological framework of lifestyle change in the very advanced stages of kidney disease, the potential synergies between environment, diet, and exercise may improve the physical and mental health of the patients and reduce the impact of dialysis.

Delayed post-dialysis recovery times are associated with relative changes in intracellular and extracellular fluid ratios between different body compartments

INTRODUCTION

Hemodialysis patient groups have advocated reducing dialysis fatigue and symptoms. We investigated whether compartmental fluid shifts were associated with peri-dialytic fatigue and symptoms.

METHODS

Sessional dialysis records of patients reporting both a short and delayed recovery (<1 h and ≥1 h) with corresponding bioimpedance measurements were reviewed.

RESULTS

One hundred and twenty-four patients reported both short and delayed recovery times, mean age 66.0 ± 14.8 years, 66.1% male. Differences between sessions included higher distress thermometer [4 (1-6) vs. 3 (0-5)], fatigue [4 (0-9) vs. 2 (0-7)], total symptom scores [20.5 (12.3-34.5) vs. 16 (7-28)], change in extracellular water to total body water ratios between body compartments [right leg/left arm 2.36 (1.23-4.19) vs. 1.28 (0.12-2.01), all p < 0.01] with delayed recovery, and more hemodialysis than hemodiafiltration sessions (χ2 4.6, p = 0.02).

CONCLUSION

Sessions with prolonged recovery times were associated with more peri-dialytic symptoms, psychological distress, and hemodialysis mode, and greater changes in compartmental fluid shifts.

Comparative effectiveness of an individualized model of hemodialysis vs conventional hemodialysis: a study protocol for a multicenter randomized controlled trial (the TwoPlus trial)

BACKGROUND

Most patients starting chronic in-center hemodialysis (HD) receive conventional hemodialysis (CHD) with three sessions per week targeting specific biochemical clearance. Observational studies suggest that patients with residual kidney function can safely be treated with incremental prescriptions of HD, starting with less frequent sessions and later adjusting to thrice-weekly HD. This trial aims to show objectively that clinically matched incremental HD (CMIHD) is non-inferior to CHD in eligible patients.

METHODS

An unblinded, parallel-group, randomized controlled trial will be conducted across diverse healthcare systems and dialysis organizations in the USA. Adult patients initiating chronic hemodialysis (HD) at participating centers will be screened. Eligibility criteria include receipt of fewer than 18 treatments of HD and residual kidney function defined as kidney urea clearance ≥3.5 mL/min/1.73 m2 and urine output ≥500 mL/24 h. The 1:1 randomization, stratified by site and dialysis vascular access type, assigns patients to either CMIHD (intervention group) or CHD (control group). The CMIHD group will be treated with twice-weekly HD and adjuvant pharmacologic therapy (i.e., oral loop diuretics, sodium bicarbonate, and potassium binders). The CHD group will receive thrice-weekly HD according to usual care. Throughout the study, patients undergo timed urine collection and fill out questionnaires. CMIHD will progress to thrice-weekly HD based on clinical manifestations or changes in residual kidney function. Caregivers of enrolled patients are invited to complete semi-annual questionnaires. The primary outcome is a composite of patients' all-cause death, hospitalizations, or emergency department visits at 2 years. Secondary outcomes include patient- and caregiver-reported outcomes. We aim to enroll 350 patients, which provides ≥85% power to detect an incidence rate ratio (IRR) of 0.9 between CMIHD and CHD with an IRR non-inferiority of 1.20 (α = 0.025, one-tailed test, 20% dropout rate, average of 2.06 years of HD per patient participant), and 150 caregiver participants (of enrolled patients).

DISCUSSION

Our proposal challenges the status quo of HD care delivery. Our overarching hypothesis posits that CMIHD is non-inferior to CHD. If successful, the results will positively impact one of the highest-burdened patient populations and their caregivers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05828823. Registered on 25 April 2023.

Coronary Artery Disease in Patients Undergoing Hemodialysis: A Problem that Sounds the Alarm

Chronic kidney disease (CKD) is affecting more and more individuals over time. The importance of the increased prevalence is enhanced by the close association with the increased risk of poor individual outcomes such as death, fatal and non-fatal cardiovascular (CV) events and progression to end stage kidney disease (ESKD). ESKD requires replacement treatment such as hemodialysis (HD), a particular and complex context that unfortunately has been rarely considered in observational studies in the last few decades. The current perspective of HD as a bridge to kidney transplant requires greater attention from observational and experimental research both in the prevention and treatment of CV events in ESKD patients. We present a narrative review by performing a literature review to extrapolate the most significant articles exploring the CV risk, in particular coronary artery disease (CAD), in ESKD and evaluating possible innovative diagnostic and therapeutic tools in these patients. The risk of CAD increases linearly when the estimated glomerular filtration rate (eGFR) declines and reached the most significant level in ESKD patients. Several diagnostic techniques have been evaluated to predict CAD in ESKD such as laboratory tests (Troponin-T, N-terminal pro b-type natriuretic peptide, alkaline phosphatase), echocardiography and imaging techniques for vascular calcifications evaluation. Similarly, treatment is based on lifestyle changes, medical therapy and invasive techniques such as coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI). Unfortunately in the literature there are no clear indications of the usefulness and validity of biomarkers and possible treatments in ESKD patients. Considering the ESKD weight in terms of prevalence and costs it is necessary to implement clinical research in order to develop prognostic reliable biomarkers for CV and CAD risk prediction, in patients with ESKD. It should be highlighted that HD is a peculiar setting that offers the opportunity to implement research and facilitates patient monitoring by favoring the design of clinical trials.

Core Patient-Reported Outcomes for Trials in Nephrology

The outcomes reported in trials across all stages of chronic kidney disease (CKD) are highly variable and often do not include outcomes that are directly relevant to patients and caregivers. Frequently, the outcomes reported in trials are often unvalidated surrogate biochemical end points. The omission of outcomes that are meaningful and important to patients can diminish the value of trials in supporting treatment decisions. In response, there have been increasing efforts across many health and medical disciplines to develop core outcome sets, defined as the minimum set of outcomes to be reported in all trials in a specific health area to improve the relevance and consistency of reporting trial outcomes. The international Standardized Outcomes in Nephrology (SONG) initiative was established in 2014 and has since developed seven core outcome sets for different diagnosis and treatment stages of CKD. The core outcomes were based on consensus among patients, caregivers, and health professionals. Each core outcome set includes at least one patient-reported outcome, including fatigue (hemodialysis), life participation (kidney transplantation, peritoneal dialysis, early CKD not yet requiring kidney replacement therapy, children and adolescents, and glomerular disease), and pain (polycystic kidney disease). This article outlines how patient-reported outcomes are currently reported in trials, discusses core patient-reported outcomes that have been established for trials in kidney disease, and outlines strategies for implementing core patient-reported outcomes in trials.

Measuring Social Functioning in Chronic Kidney Disease

Social functioning is a key aspect of daily life and is important to patients living with chronic kidney disease (CKD) and their caregivers. Many patients with CKD experience debilitating symptoms and treatment burden that can diminish their social functioning and thereby overall social health, which is the aspect of a person's well-being relating to their interactions and connections with others. In patients with CKD, symptoms (e.g., fatigue and pain), burden of ongoing treatments (including kidney replacement therapies), and medication side effects can impair social functioning. Having to manage responsibilities of self-management, which can include time-consuming and invasive treatments such as dialysis, can severely limit social functioning in patients with CKD. This can lead to poor social connections at many levels, including with family, friends, peers, and colleagues, and can hinder the development of new relationships. Patients with CKD with poorer social functioning have been reported to have worse quality of life and impaired mental health. Many patients with CKD rely on an informal caregiver-usually a family member or friend-to assist with management of their disease. This can place strain on the caregiver, further limiting opportunities for social connections for both the patient and caregiver. Although social functioning is critical for the overall well-being of patients with CKD, it remains underaddressed clinically, and patient-reported outcome measures (PROMs) to assess social functioning are limited. The objective of this article is to define social functioning, discuss the impacts of social functioning in patients with CKD and their caregivers, outline PROMs that have included assessment of social functioning, and discuss considerations in developing an appropriate PROM to measure social functioning in patients with CKD. This may help to inform the evaluation of interventions and care regarding social functioning within the CKD population.

Evaluating Medical Devices in Nephrology Using Patient-Reported Outcome and Experience Measures

Incorporating the patient's perspective into the entire product life cycle of medical device development is paramount for ensuring patient-centric evaluation. By prioritizing patient-centric evaluation, medical device developers can better address patient needs and enhance the quality and effectiveness of health care solutions. Patient-reported outcomes (PROs), patient preference information (PPI), and qualitative inquiry are methodologies to incorporate and amplify the patient's voice. In nephrology, unlike in other clinical domains, the utilization of PROs, PPI, and qualitative inquiry in medical device development has been notably sparse. Consequently, a glaring absence of patient involvement in the development of devices leaves the impact of these devices on patient well-being and functionality largely unexplored. Many forward-thinking programs as well as Food and Drug Administration guidance on the use of PROs and PPI are effectively bringing PROs into nephrology device development. Many resources exist to help researchers select high-quality PROs. There are unique considerations for using PROs and PPI to support regulatory decision-making, including fit-for-purpose, concepts of interest, context of use, and least burdensome selection. The rapid evolution of patient-centric initiatives in nephrology will serve to ensure that medical devices meet the needs of people with kidney disease and improve the quality of care.

Research on comprehensive analysis of patient comfort and complication rate using haemodialysis indwelling needles in AVF puncture in haemodialysis treatment

Traditional needles for haemodialysis access can cause complications and discomfort. Indwelling needles may have advantages, but their efficacy needs to be investigated. Our study sought to compare the safety and efficacy of indwelling needles to traditional needles for haemodialysis access. A single-center retrospective study at the Pingyang County Hospital of Traditional Chinese Medicine included 70 haemodialysis patients. The intervention group used indwelling needles, whereas the control group used traditional needles. The rate of complications, limb mobility, blood chemistry, puncture success rates, operation times, haemostasis times, pain and comfort scores, and internal fistula failure rates were all compared. Overall, complication rates were slightly higher in the control group, but not statistically significant. Both groups improved their limb mobility and blood chemistry, but there were no significant differences. The intervention group had significantly higher puncture success rates (88.4% vs. 80.0%), shorter operation times (65.4 vs. 72.3 seconds), and faster haemostasis times (23.7 vs. 28.2 seconds) than the control group. Patients in the intervention group experienced less pain (3.7 vs. 4.2) and more comfort (8.1 vs. 7.5). The intervention group had slightly lower internal fistula failure rates (2.9% vs. 5.7%), but the difference was not statistically significant. Indwelling needles appear to improve puncture efficiency and patient comfort during hemodialysis.

Narrative Review: Clinical Implications and Assessment of Frailty in Patients With Advanced CKD

Frailty is a multidimensional clinical syndrome characterized by low physical activity, reduced strength, accumulation of multiorgan deficits, decreased physiological reserve, and vulnerability to stressors. Frailty has key social, psychological, and cognitive implications. Frailty is accelerated by uremia, leading to a high prevalence of frailty in patients with advanced chronic kidney disease (CKD) and end-stage kidney disease (ESKD) as well as contributing to adverse outcomes in this patient population. Frailty assessment is not routine in patients with CKD; however, a number of validated clinical assessment tools can assist in prognostication. Frailty assessment in nephrology populations supports shared decision-making and advanced communication and should inform key medical transitions. Frailty screening and interventions in CKD or ESKD are a developing research priority with a rapidly expanding literature base.

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.

Effectiveness of Existing Insomnia Therapies for Patients Undergoing Hemodialysis : A Randomized Clinical Trial

BACKGROUND

Chronic insomnia is common in patients undergoing in-center hemodialysis, yet there is limited evidence on effective treatments for this population.

OBJECTIVE

To compare the effectiveness of cognitive behavioral therapy for insomnia (CBT-I), trazodone, and placebo for insomnia in patients undergoing long-term hemodialysis.

DESIGN

Randomized, multicenter, double-blinded, placebo-controlled trial. (ClinicalTrials.gov: NCT03534284).

SETTING

26 dialysis units in Albuquerque, New Mexico, and Seattle, Washington.

PARTICIPANTS

Patients with Insomnia Severity Index (ISI) score of 10 or greater, with sleep disturbances on 3 or more nights per week for 3 or more months.

INTERVENTION

Participants were randomly assigned to 6 weeks of CBT-I, trazodone, or placebo.

MEASUREMENTS

The primary outcome was the ISI score at 7 and 25 weeks from randomization.

RESULTS

A total of 923 patients were prescreened, and of the 411 patients with chronic insomnia, 126 were randomly assigned to CBT-I (n = 43), trazodone (n = 42), or placebo (n = 41). The change in ISI scores from baseline to 7 weeks with CBT-I or trazodone was no different from placebo: CBT-I, -3.7 (95% CI, -5.5 to -1.9); trazodone, -4.2 (CI, -5.9 to -2.4); and placebo, -3.1 (CI, -4.9 to -1.3). There was no meaningful change in ISI scores from baseline to 25 weeks: CBT-I, -4.8 (CI, -7.0 to -2.7); trazodone, -4.0 (CI, -6.0 to -1.9); and placebo, -4.3 (CI, -6.4 to -2.2). Serious adverse events (SAEs), particularly serious cardiovascular events, were more frequent with trazodone (annualized cardiovascular SAE incidence rates: CBT-I, 0.05 [CI, 0.00 to 0.29]; trazodone, 0.64 [CI, 0.34 to 1.10]; and placebo, 0.21 [CI, 0.06 to 0.53]).

LIMITATION

Modest sample size and most participants had mild or moderate insomnia.

CONCLUSION

In patients undergoing hemodialysis with mild or moderate chronic insomnia, there was no difference in the effectiveness of 6 weeks of CBT-I or trazodone compared with placebo. The incidence of SAEs was higher with trazodone.

PRIMARY FUNDING SOURCE

National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A comparison of arteriovenous fistula failure between Malaysian and Australian and New Zealand participants enrolled in the FAVOURED trial

AIM

To describe and compare de novo arteriovenous fistula (AVF) failure rates between Australia and New Zealand (ANZ), and Malaysia.

BACKGROUND

AVFs are preferred for haemodialysis access but are limited by high rates of early failure.

METHODS

A post hoc analysis of 353 participants from ANZ and Malaysia included in the FAVOURED randomised-controlled trial undergoing de novo AVF surgery was performed. Composite AVF failure (thrombosis, abandonment, cannulation failure) and its individual components were compared between ANZ (n = 209) and Malaysian (n = 144) participants using logistic regression adjusted for patient- and potentially modifiable clinical factors.

RESULTS

Participants' mean age was 55 ± 14.3 years and 64% were male. Compared with ANZ participants, Malaysian participants were younger with lower body mass index, higher prevalence of diabetes mellitus and lower prevalence of cardiovascular disease. AVF failure was less frequent in the Malaysian cohort (38% vs 54%; adjusted odds ratio (OR) 0.53, 95% confidence interval (CI) 0.31-0.93). This difference was driven by lower odds of cannulation failure (29% vs 47%, OR 0.45, 95% CI 0.25-0.80), while the odds of AVF thrombosis (17% vs 20%, OR 1.24, 95% CI 0.62-2.48) and abandonment (25% vs 23%, OR 1.17, 95% CI 0.62-2.16) were similar.

CONCLUSIONS

The risk of AVF failure was significantly lower in Malaysia compared to ANZ and driven by a lower risk of cannulation failure. Differences in practice patterns, including patient selection, surgical techniques, anaesthesia or cannulation techniques may account for regional outcome differences and warrant further investigation.

Symptom Science in Kidney Disease

Physical and emotional symptoms are highly prevalent among patients with kidney disease and are directly linked to impaired health-related quality of life. Symptom science is a field of research aimed at advancing knowledge of the holistic mechanisms driving symptoms, how best to assess symptoms accurately, and developing novel and patient-centered approaches to symptom management. Patients with kidney disease have identified symptom science as a top research priority, and opportunities abound for ongoing patient engagement in symptom-related research efforts and clinical care. This review describes the burden of symptoms experienced by patients with kidney disease, explores the spectrum of patient engagement in symptom care and research, and discusses approaches for symptom assessment and management, taking into consideration the multitude of factors that may contribute to symptoms.

Advancing Exercise Science for Better Health Outcomes Across the Spectrum of Chronic Kidney Disease

Despite over 30 years of evidence for improvements in physical function, physical fitness, and health-related quality of life with exercise training in individuals with chronic kidney disease, access to dedicated exercise training programs remains outside the realm of standard of care for most kidney care programs. In this review, we explore possible reasons for this by comparing approaches in other chronic diseases where exercise rehabilitation has become the standard of care, identifying enablers and factors that need to be addressed for continued growth in this area, and discussing knowledge gaps for future research. For exercise rehabilitation to be relevant to all stakeholders and become a sustainable component of kidney care, a focus on the effect of exercise on clinically relevant outcomes that are prioritized by individuals living with kidney disease, use of evidence-based implementation strategies for diverse settings and populations, and approaching exercise as a medical therapy are required.

Decision aids to assist patients and professionals in choosing the right treatment for kidney failure

Background

Kidney services vary in the way they involve people with kidney failure (PwKF) in treatment decisions as management needs change. We discuss how decision-science applications support proactively PwKF to make informed decisions between treatment options with kidney professionals.

Methods

A conceptual review of findings about decision making and use of decision aids in kidney services, synthesized with reference to: the Making Informed Decisions-Individually and Together (MIND-IT) multiple stakeholder decision makers framework; and the Medical Research Council-Complex Intervention Development and Evaluation research framework.

Results

This schema represents the different types of decision aids that support PwKF and professional reasoning as they manage kidney disease individually and together; adjustments at micro, meso and macro levels supports integration in practice.

Conclusion

Innovating services to meet clinical guidelines on enhancing shared decision making processes means enabling all stakeholders to use decision aids to meet their goals within kidney pathways at individual, service and organizational levels.

Interventions for fatigue in people with kidney failure requiring dialysis

BACKGROUND

Fatigue is a common and debilitating symptom in people receiving dialysis that is associated with an increased risk of death, cardiovascular disease and depression. Fatigue can also impair quality of life (QoL) and the ability to participate in daily activities. Fatigue has been established by patients, caregivers and health professionals as a core outcome for haemodialysis (HD).

OBJECTIVES

We aimed to evaluate the effects of pharmacological and non-pharmacological interventions on fatigue in people with kidney failure receiving dialysis, including HD and peritoneal dialysis (PD), including any setting and frequency of the dialysis treatment.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 18 October 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Studies evaluating pharmacological and non-pharmacological interventions affecting levels of fatigue or fatigue-related outcomes in people receiving dialysis were included. Studies were eligible if fatigue or fatigue-related outcomes were reported as a primary or secondary outcome. Any mode, frequency, prescription, and duration of therapy were considered.

DATA COLLECTION AND ANALYSIS

Three authors independently extracted data and assessed the risk of bias. Treatment estimates were summarised using random effects meta-analysis and expressed as a risk ratio (RR) or mean difference (MD), with a corresponding 95% confidence interval (CI) or standardised MD (SMD) if different scales were used. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Ninety-four studies involving 8191 randomised participants were eligible. Pharmacological and non-pharmacological interventions were compared either to placebo or control, or to another pharmacological or non-pharmacological intervention. In the majority of domains, risks of bias in the included studies were unclear or high. In low certainty evidence, when compared to control, exercise may improve fatigue (4 studies, 217 participants (Iowa Fatigue Scale, Modified Fatigue Impact Scale, Piper Fatigue Scale (PFS), or Haemodialysis-Related Fatigue scale score): SMD -1.18, 95% CI -2.04 to -0.31; I2 = 87%) in HD. In low certainty evidence, when compared to placebo or standard care, aromatherapy may improve fatigue (7 studies, 542 participants (Fatigue Severity Scale (FSS), Rhoten Fatigue Scale (RFS), PFS or Brief Fatigue Inventory score): SMD -1.23, 95% CI -1.96 to -0.50; I2 = 93%) in HD. In low certainty evidence, when compared to no intervention, massage may improve fatigue (7 studies, 657 participants (FSS, RFS, PFS or Visual Analogue Scale (VAS) score): SMD -1.06, 95% CI -1.47, -0.65; I2 = 81%) and increase energy (2 studies, 152 participants (VAS score): MD 4.87, 95% CI 1.69 to 8.06, I2 = 59%) in HD. In low certainty evidence, when compared to placebo or control, acupressure may reduce fatigue (6 studies, 459 participants (PFS score, revised PFS, or Fatigue Index): SMD -0.64, 95% CI -1.03 to -0.25; I2 = 75%) in HD. A wide range of heterogenous interventions and fatigue-related outcomes were reported for exercise, aromatherapy, massage and acupressure, preventing our capability to pool and analyse the data. Due to the paucity of studies, the effects of pharmacological and other non-pharmacological interventions on fatigue or fatigue-related outcomes, including non-physiological neutral amino acid, relaxation with or without music therapy, meditation, exercise with nandrolone, nutritional supplementation, cognitive-behavioural therapy, ESAs, frequent HD sections, home blood pressure monitoring, blood flow rate reduction, serotonin reuptake inhibitor, beta-blockers, anabolic steroids, glucose-enriched dialysate, or light therapy, were very uncertain. The effects of pharmacological and non-pharmacological treatments on death, cardiovascular diseases, vascular access, QoL, depression, anxiety, hypertension or diabetes were sparse. No studies assessed tiredness, exhaustion or asthenia. Adverse events were rarely and inconsistently reported.

AUTHORS' CONCLUSIONS

Exercise, aromatherapy, massage and acupressure may improve fatigue compared to placebo, standard care or no intervention. Pharmacological and other non-pharmacological interventions had uncertain effects on fatigue or fatigue-related outcomes in people receiving dialysis. Future adequately powered, high-quality studies are likely to change the estimated effects of interventions for fatigue and fatigue-related outcomes in people receiving dialysis.

The hemoglobin, albumin, lymphocyte, and platelet (HALP) is a potent indicator for the prognosis in hemodialysis patients

The hemoglobin, albumin, lymphocyte, and platelet (HALP) values were marked as a original index of general nutritional and inflammatory conditions. The purpose of this investigation was to evaluate the potential relationship between HALP and prognosis in hemodialysis (HD) patients. Patients with maintenance HD from multiple dialysis centers in China were retrospectively analyzed. The primary poor outcome were cardiovascular disease (CVD) and all-cause death. The computational equation of HALP values as the follows: hemoglobin (g/L) × albumin (g/L) × lymphocytes (/L)/ platelets (/L). All participants were divided into Tertile 1, Tertile 2, and Tertile 3 according to the tertiles of baseline HALP values. The Kaplan-Meier curve and the Cox regression was done to figure out the relationship about HALP and adverse outcomes. The restricted cubic splines further identified the possible associations. The time-dependent receiver operating characteristic curve and C-index were implemented for evaluate the predictive values of the HALP composite model. There were 4796 patients incorporate into ultimate study. Compared with patients in Tertile 1, patients in Tertile 3 had an lower risk of all-cause mortality [hazard ratios = 0.66, 95% confidence intervals: 0.49-0.86, P = .007] and CVD mortality [sub-distribution hazard ratio = 0.51, 95% confidence intervals: 0.34-0.80, P = .005]. The composite model with the supplement of HALP outperformed the traditional factor model in the time-dependent receiver operating characteristic curve. High HALP values at baseline are related to a diminished risk of CVD death and all-cause death in HD patients. HALP is a novel and potent index for the prognosis of HD patients.

Australian Workshops on Patients' Perspectives on Hemodialysis and Incremental Start

Introduction

Most patients with kidney failure commence and continue hemodialysis (HD) thrice weekly. Incremental initiation (defined as HD less than thrice weekly) is increasingly considered to be safe and less burdensome, but little is known about patients' perspectives. We aimed to describe patients' priorities and concerns regarding incremental HD.

Methods

Patients currently, previously, or soon to be receiving HD in Australia participated in two 90-minute online workshops to discuss views about HD focusing on incremental start and priorities for trial outcomes. Transcripts were analyzed using thematic analysis. Outcomes were ranked on the basis of the sum of participants' priority scores (i.e., single allocation of 3 points for most important, 2 for second, and 1 for third most important outcome).

Results

All 26 participants (1 caregiver and 25 patients) preferred an incremental HD approach. The top prioritized outcomes were quality of life (QOL) (56 points), residual kidney function (RKF) (27 points), and mortality (16 points). The following 4 themes underpinning outcome priorities, experience, and safety concerns were identified: (i) unpreparedness and pressure to adapt, (ii) disruption to daily living, (iii) threats to safety, and (iv) hope and future planning.

Conclusion

Patients with kidney failure preferred an incremental start to HD to minimize disruption to daily living and reduce the negative impacts on their education, ability to work, and family life. QOL was the most critically important outcome, followed by RKF and survival.

Association between negative psychology and sleep quality in dialysis patients during the COVID-19 pandemic

AIMS AND OBJECTIVES

The aim of this study was to assess the sleep quality in dialysis patients during the COVID-19 epidemic and explore the association between negative psychology (including depression, anxiety, and stress) and sleep quality in this population.

DESIGN

A cross-sectional study including three centres.

METHODS (PATIENTS OR PUBLIC CONTRIBUTION)

This cross-sectional study included 378 dialysis patients from April to May 2022 in three dialysis centres in Shanghai.

METHODS

Depression, anxiety, stress, and sleep quality were measured by the Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale-14 (PSS-14), and Pittsburgh sleep quality index (PSQI), respectively. With a threshold of 5 to classify participants into good and poor sleep quality, with HADS/PSS-14 scores as independent variables (per standard deviation (SD) increment), respectively and binary Logistic regression model was constructed to explore the association between the three negative psychological aspects of depression, anxiety, and stress and sleep quality.

RESULTS

The median PSQI score was 11.0 (mean ± SD: 11.8 ± 4.8). Among them, poor sleep quality (i.e., PSQI >5) was reported by 90.2% of participants. After adjusting for sociodemographic and disease-related information, HADS-depression was associated with a significant 49% (odds ratio (OR): 1.49; 95% CI 1.02-2.18) increase in the risk of poor sleep quality for each additional SD (2.4). Correspondingly, for each SD (7.1) increase in PSS-14, the risk of poor sleep quality was significantly increased by 95% (OR: 1.95; 95% CI 1.35-2.82).

CONCLUSION

During the COVID-19 pandemic, there was a significant negative association between negative psychology, such as depression and stress, and sleep quality in dialysis patients, and this relationship was independent of the dialysis modality.

RELEVANCE TO CLINICAL PRACTICE

In the context of the rampant COVID-19, the vast majority of dialysis-dependent chronic kidney disease presents with severe sleep quality problems, and negative psychology is a potential influencing factor.

Physical activity is a potential measure of physical resilience in older adults receiving hemodialysis

Background

Physical resilience, or the ability to recover after a physical stressor, declines with aging. Efforts to preserve physical resilience in the older dialysis population are critically needed; however, validated, patient-centered measures that are sensitive to change are also needed. Our objective was to assess accelerometer-derived step count variability, or a measure of intra-individual variation in physical activity, as a potential measure of physical resilience among older adults receiving hemodialysis.

Methods

Community-dwelling ambulatory older adults receiving in-center hemodialysis were prospectively enrolled. Participants wore wrist accelerometers during daytime hours on both dialysis and non-dialysis days up to 14 days, and the feasibility of accelerometer use was assessed from wear time. We used accelerometer data to compute step counts in 4-hour blocks and step count variability. Physical function was assessed with the Short Physical Performance Battery (SPPB which includes gait speed test), grip strength, activities of daily living (ADLs) instruments, and life space mobility. We assessed interval fatigue (subjective rating from 0 to 10) on dialysis and non-dialysis days and self-reported recovery time. We assessed the correlations of step count variability with measures of physical function and step count and interval fatigue.

Results

Of 37 enrolled participants, 29 had sufficient accelerometer data for analyses. Among the 29 participants, mean (SD) age was 70.6(4.8) years, and 55% (n=16) were male and 72% (n=21) were Black race. Participants were largely sedentary with median (Q1-Q3) self-reported total kilocalories per week of 200 (36-552). Step count variability was positively correlated with measures of physical function: SPPB (r=0.50, p<0.05), gait speed (r=0.59, p<0.05), handgrip strength (r=0.71, p<0.05), Instrumental ADLs (r=0.44, p<0.05) and life space mobility (r=0.54, p<0.05).There was a weak inverse correlation between post-dialysis step counts (4-hour blocks after a dialysis session) and post-dialysis interval fatigue [r=-0.19 (n=102, p=0.06).

Conclusions

Physical activity assessment via accelerometer is feasible for older adults receiving hemodialysis. Step count variability correlated with physical function, so it may be a novel measure of physical resilience. Further studies are needed to validate this measure.

Prevalence and Risk Factors of Postdialysis Fatigue in Patients Under Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

PURPOSE

Despite the high prevalence of postdialysis fatigue (PDF) in maintenance hemodialysis patients, no meta-analysis on the prevalence and risk factors of PDF has yet been published. This study aimed to identify the prevalence of PDF and explore its related factors.

METHODS

PubMed, Embase, CENTRAL, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the four Chinese databases (National Knowledge Infrastructure [CNKI], Chinese Biomedical Literature database [SinoMed], Wanfang Digital Periodicals [WANFANG], and Chinese Science and Technology Periodicals [VIP] database) were searched from inception up to July 2022. This study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The articles were independently searched by two reviewers, and the relevant data were extracted. The Agency for Healthcare Research and Quality was used to assess the quality of the included studies.

RESULTS

Thirteen articles with 2,118 participants were included. The pooled prevalence was 60.0%. The meta-analysis results revealed that the ultrafiltration volume, mean arterial pressure after dialysis, and good sleep quality were potentially associated with PDF, whereas only good sleep quality (odds ratio 0.24, 95% confidence interval 0.19-0.30) was significantly associated with PDF.

CONCLUSION

PDF is common in maintenance hemodialysis patients, which is related to the ultrafiltration volume, sleep quality, and mean arterial pressure after dialysis. However, the mechanism underlying the risk factors and PDF remains unknown. Further research is warranted to investigate the risk factors, intervention, treatment, and mechanism in maintenance hemodialysis patients.

Study protocol for Vascular Access outcome measure for function: a vaLidation study In hemoDialysis (VALID)

Background

A functioning vascular access (VA) is crucial to providing adequate hemodialysis (HD) and considered a critically important outcome by patients and healthcare professionals. A validated, patient-important outcome measure for VA function that can be easily measured in research and practice to harvest reliable and relevant evidence for informing patient-centered HD care is lacking. Vascular Access outcome measure for function: a vaLidation study In hemoDialysis (VALID) aims to assess the accuracy and feasibility of measuring a core outcome for VA function established by the international Standardized Outcomes in Nephrology (SONG) initiative.

Methods

VALID is a prospective, multi-center, multinational validation study that will assess the accuracy and feasibility of measuring VA function, defined as the need for interventions to enable and maintain the use of a VA for HD.

The primary objective is to determine whether VA function can be measured accurately by clinical staff as part of routine clinical practice (Assessor 1) compared to the reference standard of documented VA procedures collected by a VA expert (Assessor 2) during a 6-month follow-up period. Secondary outcomes include feasibility and acceptability of measuring VA function and the time to, rate of, and type of VA interventions.

An estimated 612 participants will be recruited from approximately 10 dialysis units of different size, type (home-, in-center and satellite), governance (private versus public), and location (rural versus urban) across Australia, Canada, Europe, and Malaysia.

Validity will be measured by the sensitivity and specificity of the data acquisition process. The sensitivity corresponds to the proportion of correctly identified interventions by Assessor 1, among the interventions identified by Assessor 2 (reference standard). The feasibility of measuring VA function will be assessed by the average data collection time, data completeness, feasibility questionnaires and semi-structured interviews on key feasibility aspects with the assessors.

Discussion

Accuracy, acceptability, and feasibility of measuring VA function as part of routine clinical practice are required to facilitate global implementation of this core outcome across all HD trials. Global use of a standardized, patient-centered outcome measure for VA function in HD research will enhance the consistency and relevance of trial evidence to guide patient-centered care.

Trial registration

Clinicaltrials.gov: NCT03969225. Registered on 31st May 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02987-1.

Polymethylmethacrylate Membrane Dialyzer: Historic but Modern

Polymethylmethacrylate (PMMA) hollow fiber membranes are one of the synthetic polymer hollow fiber membranes used to the hollow fiber artificial kidney. A PMMA hollow fiber membrane (PMMA membrane) has unique properties including the uniform structure and the adsorption property. Hemodialyzers using PMMA membranes, Filtryzer®, were approved in Japan in 1977 and have been used worldwide for over 40 years and so is a historical hemodialyzer.Various types in Filtryzer® having different pore sizes are developed and used in the clinical field. Filtryzer® B3 is a low-flux dialyzer. Filtryzer® BK has three types having different pore sizes, and above all, BK-F has the largest pores in the Filtryzer® series. Filtryzer® BG has a more uniform membrane structure by using weak anionic polymers compared with the earlier Filtryzer® series to remove β2-MG more. Filtryzer® NF is the latest Filtryzer® series and was developed as a dialyzer having improved antithrombogenicity compared with previous models and having protein adsorption property as the same with them. There have been many reports concerning Filtryzer® including improvement of patients' symptoms such as pruritus and nutrition on the advantages for dialysis patients. Although PMMA membranes are historic dialysis tools used for over 40 years, they are also modern dialysis membranes that have been updated to respond to dialysis therapy at those time.

Adapting a Dialysis Service for Delivery of Percutaneous Arteriovenous Fistulas

The percutaneous arteriovenous fistula (pAVF) is an exciting and novel addition to the vascular access options available to patients with end-stage kidney disease who require dialysis. Early clinical results have been promising, with high rates of maturation and low rates of reintervention. To successfully adapt an existing hemodialysis service to include the provision of pAVF formation, it is essential to identify and align the interests of key clinical and nonclinical stakeholders. Only through strong collaboration can the service be supported. The authors provide a comprehensive overview of the planning fundamentals required, including the referral pathway, screening and clinical assessment, and practical procedural elements and considerations, as well as follow-up requirements such as cannulation, fistula surveillance, and maintenance. Key staffing requirements are highlighted, including those pertaining to vascular US screening and dialysis nurse training. A broad and structured planning approach ensures that the entire network of key stakeholder interests is included and provides a strong foundation for a compelling business plan to attract the necessary funding and managerial support for the service. The authors present a systematic framework of the essential considerations necessary to facilitate the planning, funding, and ultimately delivery of a successful pAVF service. Online supplemental material is available for this article. ^©RSNA, 2022.

Epidemiology of peritoneal dialysis outcomes

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.

The use of peritoneal dialysis (PD) can be advantageous compared with haemodialysis treatment, although several barriers limit its broad implementation. This review examines the epidemiology of peritoneal dialysis (PD) outcomes, including clinical, patient-reported and surrogate PD outcomes.

Peritoneal dialysis (PD) has distinct advantages compared with haemodialysis, including the convenience of home treatment, improved quality of life, technical simplicity, lesser need for trained staff, greater cost-effectiveness in most countries, improved equity of access to dialysis in resource-limited settings, and improved survival, particularly in the first few years of initiating therapy.

Important barriers can hamper PD utilization in low-income settings, including the high costs of PD fluids (owing to the inability to manufacture them locally and the exorbitant costs of their import), limited workforce availability and a practice culture that limits optimal PD use, often leading to suboptimal outcomes.

PD outcomes are highly variable around the world owing in part to the use of variable outcome definitions, a heterogeneous practice culture, the lack of standardized monitoring and reporting of quality indicators, and kidney failure care gaps (including health care workforce shortages, inadequate health care financing, suboptimal governance and a lack of good health care information systems).

Key outcomes include not only clinical outcomes (typically defined as medical outcomes based on clinician assessment or diagnosis) — for example, PD-related infections, technique survival, mechanical complications, hospitalizations and PD-related mortality — but also patient-reported outcomes. These outcomes are directly reported by patients and focus on how they function or feel, typically in relation to quality of life or symptoms; patient-reported outcomes are used less frequently than clinical outcomes in day-to-day routine care.

A Systematic Review of Reported Outcomes in ADPKD Studies

Introduction

Methods

Results

Conclusion

Time on Therapy of Automated Peritoneal Dialysis with and without Remote Patient Monitoring: A Cohort Study

Background. Remote patient monitoring (RPM) of patients undergoing automated peritoneal dialysis (APD-RPM) may potentially enhance time on therapy due to possible improvements in technique and patient survival. Objective. To evaluate the effect of APD-RPM as compared to APD without RPM on time on therapy. Methods. Adult incident APD patients undergo APD for 90 days or more in the Baxter Renal Care Services (BRCS) Colombia network between January 1, 2017, and June 30, 2019, with the study follow-up ending June 30, 2021. The exposure variable was APD-RPM vs. APD-without RPM. The outcomes of time on therapy and mortality rate over two years of follow-up were estimated in the full sample and in a matched population according to the exposure variable. A propensity score matching (PSM) 1:1 without replacement utilizing the nearest neighbor within caliper (0.035) was used and created a pseudopopulation in which the baseline covariates were well balanced. Fine & Gray multivariate analysis was performed to assess the effect of demographic, clinical, and laboratory variables on the risk of death, adjusting for the competing risks of technique failure and kidney transplantation. Results. In the matched sample, the time on APD therapy was significantly longer in the RPM group than in the non-RPM group, 18.95 vs. 15.75 months, $p<0.001$ . The mortality rate did not differ between the two groups: 0.10 events per patient-year in the RPM group and 0.12 in the non-RPM group, $p=0.325$ . Conclusion. Over two years of follow-up, the use of RPM vs. no RPM in APD patients was associated with a significant increase in time on therapy, by 3.2 months. This result indicates that RPM-supported APD therapy may improve the clinical effectiveness and the overall quality of APD.

Person-centered climate from the perspective of hemodialysis patients and nurses working in hemodialysis units

Background

Person-centered care (PCC) is considered an important component of high-quality care in hemodialysis units. Hemodialysis patients and nurses may have different perceptions of person-centeredness in hemodialysis units. The present study aimed to assess the PCC from the perspective of hemodialysis patients and nurses working in the hemodialysis unit.

Methods

This cross-sectional study was performed on 200 patients and 71 nurses working in two hemodialysis units. Data were collected using a demographic questionnaire, person-centered climate questionnaire-patient version (PCQ-P), and person-centered climate questionnaire-staff version (PCQ-S). Data were analyzed by SPSS software (ver. 24) using ANOVA and independent t-tests.

Results

The mean score of person-centered climate from the patients' view was 81.49 ± 7.14 (Possible score: 17–102). Independent t-test showed that the mean total score of PCQ-P in patients undergoing hemodialysis in the Imam Reza Hospital (82.26 ± 7.09) was more than those undergoing hemodialysis in the Sina Hospital (78.60 ± 6.61) (P < 0.05). The mean score of the safety subscale showed a statistically significant difference between the two hemodialysis centers (P < 0.05). The mean total score of PCQ-S from the nurses' view was 66.86 ± 8.07 out of 84. The mean score of the everydayness subscale showed a statistically significant difference between nurses working in two hemodialysis units (P < 0.05).

Conclusion

Although the results showed an acceptable score in the person-centered climate questioner, it needs some improvements in the fields of safety and everydayness. The environment of the hemodialysis unit could limit or enhance the implementation of person-centered processes.

Perspectives of Patients, Nurses, and Nephrologists About Electronic Symptom Monitoring With Feedback in Hemodialysis Care

RATIONALE & OBJECTIVE

Patients receiving hemodialysis experience high symptom burden and low quality of life (QOL). Electronic patient-reported outcome measures (e-PROMs) monitoring with feedback to clinicians may be an acceptable intervention to improve health-related QOL for patients receiving hemodialysis. This study explored patient and clinician perspectives on e-PROMs monitoring with feedback to clinicians.

STUDY DESIGN

Qualitative study.

SETTING & PARTICIPANTS

41 participants (12 patients, 13 nephrologists, 16 dialysis nurses) who participated in a 6-month feasibility pilot study of adults receiving facility-based hemodialysis across 4 Australian units. The intervention consisted of electronic symptom monitoring with feedback to clinicians, who also received evidence-based symptom management recommendations to improve health-related QOL.

ANALYTICAL APPROACH

Semistructured interviews and focus group discussions explored the feasibility and acceptability of e-PROMs monitoring with feedback to clinicians. We conducted a thematic analysis of transcripts.

RESULTS

We identified 4 themes: enabling efficient, systematic, and multidisciplinary patient-centered care; experiencing limited data and options for symptom management; requiring familiarity with technology and processes; and identifying barriers and competing priorities. While insufficient patient engagement, logistic/technical challenges, and delayed symptom feedback emerged as barriers to implementation, active engagement by nurses in encouraging and supporting patients during survey completion and clinicians' prompt action after symptom feedback were considered to be facilitators to implementation.

LIMITATIONS

Limited generalizability due to inclusion of English-speaking participants only.

CONCLUSIONS

Patients, nurses, and nephrologists considered e-PROMs monitoring with feedback to clinicians feasible for symptom management in hemodialysis. Clinician engagement, patient support, reliable technology, timely symptom feedback, and interventions to address symptom burden are likely to improve its implementation within research and clinical settings.

The critical role of mixed methods research in developing valid and reliable patient-reported outcome measures

Randomised controlled clinical trials provide the gold standard for evidence underpinning clinical guidelines and patient centred care. However, this is only true when they are robustly designed, conducted and reported and then only if they include outcomes that are important to patients and clinicians. Important outcomes include those that measure impact on patient experience, quality of life, overall well-being, and physical, social, cognitive and emotional functioning, all of which require patient reported outcome measures (PROMs). Patient centred care must be underpinned by objective evidence of the effect of interventions on outcomes that are important to patients. Evidence for patient reported outcomes must be supported by valid and reliable PROMs. Importantly the PROM must reflect patient experience of the impact of the intervention on the outcome and enable quantitative evaluation of that impact. The purpose of this paper is to highlight the critical role of mixed methods research in developing PROMs that are valid (measure what they purport to measure), acceptable to those reporting the outcome and able to reliably detect meaningful differences between individuals with different conditions or severity and with time. This can only be achieved through a structured mixed methods program combining qualitative and quantitative research techniques.