No Difference in Average Interdialytic Weight Gain Observed in a Randomized Trial With a Technology-Supported Behavioral Intervention to Reduce Dietary Sodium Intake in Adults Undergoing Maintenance Hemodialysis in the United States: Primary Outcomes of the BalanceWise Study

Lifestyle interventions delivered by eHealth in chronic kidney disease: A scoping review

A method of overcoming barriers associated with implementing lifestyle interventions in CKD may be through the use of eHealth technologies. The aim of this review was to provide an up-to-date overview of the literature on this topic. Four bibliographical databases, two trial registers, and one database for conference proceedings were searched from inception to August 2023. Studies were eligible if they reported a lifestyle intervention using eHealth technologies. A narrative synthesis of the findings from the included studies structured around the type of eHealth intervention was presented. Where a sufficient number of studies overlapped in terms of the type of intervention and outcome measure these were brought together in a direction of effect plot. There were 54 included articles, of which 23 were randomised controlled trials (RCTs). The main component of the intervention for the included studies was mobile applications (n = 23), with the majority being in the dialysis population (n = 22). The majority of eHealth interventions were reported to be feasible and acceptable to participants. However, there was limited evidence that they were efficacious in improving clinical outcomes with the exception of blood pressure, intradialytic weight gain, potassium, and sodium. Although eHealth interventions appear acceptable and feasible to participants, there is insufficient evidence to make recommendations for specific interventions to be implemented into clinical care. Properly powered RCTs which not only demonstrate efficacy, but also address barriers to implementation are needed to enhance widespread adoption.

Sodium Management in Kidney Disease: Old Stories, New Tricks

Excessive dietary sodium intake is associated with an increased risk of hypertension, especially in the setting of chronic kidney disease (CKD). Although implementation of a low-sodium diet in patients with CKD generally is recommended, data supporting the efficacy of this practice is mostly opinion-based. Few controlled studies have investigated the specific association of dietary sodium intake and cardiovascular events and mortality in CKD. Furthermore, in epidemiologic studies, the association of sodium intake with CKD progression, cardiovascular risk, and mortality is not homogeneous, and both low- and high-sodium intake has been associated with adverse health outcomes in different studies. In general, the adverse effects of high dietary sodium intake are more apparent in the setting of advanced CKD. However, there is no established definitive target level of dietary sodium intake in different CKD stages based on glomerular filtration rate and albuminuria/proteinuria. This review discusses the current challenges regarding the rationale of sodium restriction, target levels and assessment of sodium intake, and interventions for sodium restrictions in CKD in relation to clinical outcomes.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 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 Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

Excessive fluid volume risk middle-range theory

ABSTRACT Objective to construct a middle range theory for developing the excessive fluid volume risk diagnostic proposition in patients undergoing hemodialysis. Method this is a methodological study, developed for the theoretical-causal validity of a nursing diagnosis. The study was carried out in four stages: study selection, identification of the main concepts of the theory, pictogram construction and proposition elaboration. These steps were operationalized through an integrative literature review, with a sample of 82 articles selected from the Web of Science, PubMed, CINAHL, Scopus and Science Direct databases. Results the data extracted from the sample articles enabled identifying five essential terms to define excessive fluid volume risk. Furthermore, 31 etiological factors of excessive fluid volume risk were identified, in addition to a pictogram and 12 propositions. Conclusion and implications for practice the construction of a middle-range theory focused on excessive fluid volume risk in patients undergoing hemodialysis refines terminology and expands the understanding of nursing phenomena. Thus, the data from this research will provide clear and robust knowledge for the conduct of nurses’ actions in clinical practice.

Teoria de médio alcance do risco de volume de líquidos excessivo

RESUMO Objetivo construir uma teoria de médio alcance para o desenvolvimento da proposição diagnóstica risco de volume de líquidos excessivo em pacientes em hemodiálise. Método trata-se de um estudo metodológico, desenvolvido para a validade teórico-causal de um diagnóstico de enfermagem. O estudo foi realizado em quatro etapas: seleção dos estudos, identificação dos conceitos principais da teoria, construção do pictograma e elaboração das proposições. Essas etapas foram operacionalizadas por meio de uma revisão integrativa da literatura, com uma amostra de 82 artigos selecionados nas bases de dados Web of Science, PubMed, CINAHL, Scopus e Science Direct. Resultados os dados extraídos dos artigos da amostra possibilitaram a identificação de cinco termos essenciais para a definição do risco de volume de líquidos excessivo. Além disso, foram identificados 31 fatores etiológicos do risco de volume de líquidos excessivo, além de construídos um pictograma e 12 proposições. Conclusão e implicações para a prática a construção de uma teoria de médio alcance voltada para o risco de volume de líquidos excessivo em pacientes em hemodiálise refina as terminologias e amplia a compreensão dos fenômenos da enfermagem. Assim, os dados desta pesquisa fornecerão conhecimentos claros e robustos para a condução das ações do enfermeiro na prática clínica.

OUP accepted manuscript

Patients on chronic hemodialysis are counseled to reduce dietary sodium intake to limit their thirst and consequent interdialytic weight gain (IDWG), chronic volume overload and hypertension. Low-sodium dietary trials in hemodialysis are sparse and mostly indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake and IDWG. Additional nutritional restrictions and numerous barriers further complicate dietary adherence. A low-sodium diet may also reduce tissue sodium, which is positively associated with hypertension and left ventricular hypertrophy. A potential alternative or complementary approach to dietary counseling is home delivery of low-sodium meals. Low-sodium meal delivery has demonstrated benefits in patients with hypertension and congestive heart failure but has not been explored or implemented in patients undergoing hemodialysis. The objective of this review is to summarize current strategies to improve volume overload and provide a rationale for low-sodium meal delivery as a novel method to reduce volume-dependent hypertension and tissue sodium accumulation while improving quality of life and other clinical outcomes in patients undergoing hemodialysis.

Reducing salt intake: a systematic review and meta-analysis of behavior change interventions in adults

CONTEXT

Prolonged high salt (sodium) intake can increase the risk of hypertension and cardiovascular disease. Behavioral interventions may help reduce sodium intake at the population level.

OBJECTIVE

The effectiveness of behavior change interventions to reduce sodium intake in adults was investigated in this systematic review and meta-analysis.

DATA SOURCE

The PubMed, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, and EMBASE databases were searched.

DATA EXTRACTION

Narrative synthesis and random-effects meta-analyses were used to determine intervention efficacy. A total of 61 trials (46 controlled trials and 15 quasi-experimental studies) were included.

RESULTS

Behavior change interventions resulted in significant improvements in salt consumption behavior (eg, decrease in purchase of salty foods; increase in use of salt substitutes), leading to reductions in sodium intake as measured by urinary sodium in 32 trials (N = 7840 participants; mean difference, -486.19 mg/d [95%CI, -669.44 to -302.95]; P < 0.001; I2 = 92%) and dietary sodium in 19 trials (N = 3750 participants; mean difference -399.86 mg/d [95%CI, -581.51 to -218.20]; P < 0.001; I2 = 96%), equivalent to a reduction of >1 g of salt intake daily. Effects were not significantly different based on baseline sodium intakes, blood pressure status, disease status, the use of behavior change theories, or the main method of intervention delivery (ie, online vs face-to-face).

CONCLUSION

Behavior change interventions are effective at improving salt consumption practices and appear to reduce salt intake by >1 g/d.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020185639.

Effects of the Combination of Auricular Acupressure and a Fluid-Restriction Adherence Program on Salivary Flow Rate, Xerostomia, Fluid Control, Interdialytic Weight Gain, and Diet-Related Quality of Life in Patients Undergoing Hemodialysis

Adherence to fluid-restriction is a clinical priority in nephrology care. This study examines the effects of a combination of auricular acupressure (AA) and a fluid-restriction adherence program on the salivary flow rate, xerostomia, fluid control, interdialytic weight gain (IDWG), and diet-related quality of life (DQOL) among hemodialysis patients in South Korea. Using a quasi-experimental design, 84 hemodialysis patients were assigned to the experimental group (AA + fluid-restriction adherence program; n = 29), the comparison group (fluid-restriction adherence program; n = 27), and the control group (usual care; n = 28). The program lasted 6 weeks, and data were collected at baseline, immediately after the intervention, and 4 months post-intervention. There was a significant interaction between group and time for salivary flow rate, fluid control, IDWG, and DQOL (all p < 0.005). Compared with the control group, the experimental group had a significantly improved salivary flow rate, fluid control, IDWG, and DQOL at weeks 6 and 22, whereas the comparison group had improved fluid control and DQOL at week 6. The combination of AA and a fluid-restriction adherence program could be provided to hemodialysis patients as cost-effective, safe, and complementary interventions to promote sustainable patient adherence to fluid-restriction.

Workforce needs and estimated costs/savings for nutrition care in chronic kidney disease-stage 3 through maintenance dialysis

The role of nutrition in chronic kidney disease (CKD) is well known. However, controversies, misconceptions, and gaps in the literature exist regarding the workforce required to provide nutrition care in CKD. This paper reviews the existing literature on this topic, focusing primarily on the United States. Topics covered in this review include the qualifications and services of the registered dietitian nutritionist (RDN), to which specific patients nutrition care should be provided in CKD and on dialysis, barriers to the utilization of nutrition services, the quantity of nutrition care needed to improve patient outcomes, and the risks of provider burnout. Controversies include whether more staffing is associated with better care and the best measures of staffing. The topics are supported with estimations for the economic impact and practicality of workforce decisions.

Incorporating digital platforms into nutritional care in chronic kidney disease

Digital health is increasingly recognized for its value to enhance patient care and clinical care processes. People with chronic kidney disease often find dietary self-management challenging. There is promising evidence that digital health interventions can support people with chronic kidney disease to self-manage their diet, by providing more frequent access to nutritional information and dietitians and by facilitating regular monitoring and feedback. There is some emerging evidence of the impact of digital interventions in chronic kidney disease; however, more research is needed to provide meaningful interpretation of how digital interventions can enhance current practice. Importantly, a number of factors need to be considered when designing, developing, implementing, and evaluating the impact of digital interventions. Consideration of the nutrition service and patients' needs, motivation and digital literacy, type of digital intervention, and the ability to embed the digital intervention into current care processes are critical. This paper overviews the current literature on digital health and self-management, factors to consider when embedding digital interventions and platforms into nutrition care and practical considerations for designing and implementing digital health interventions to enhance the nutritional care of people with chronic kidney disease.

Altered dietary salt intake for people with chronic kidney disease

BACKGROUND

Evidence indicates that reducing dietary salt may reduce the incidence of heart disease and delay decline in kidney function in people with chronic kidney disease (CKD). This is an update of a review first published in 2015.

OBJECTIVES

To evaluate the benefits and harms of altering dietary salt for adults with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 6 October 2020 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 Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials comparing two or more levels of salt intake in adults with any stage of CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility, conducted risk of bias evaluation and evaluated confidence in the evidence using GRADE. Results were summarised using random effects models as risk ratios (RR) for dichotomous outcomes or mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

MAIN RESULTS

We included 21 studies (1197 randomised participants), 12 in the earlier stages of CKD (779 randomised participants), seven in dialysis (363 randomised participants) and two in post-transplant (55 randomised participants). Selection bias was low in seven studies, high in one and unclear in 13. Performance and detection biases were low in four studies, high in two, and unclear in 15. Attrition and reporting biases were low in 10 studies, high in three and unclear in eight. Because duration of the included studies was too short (1 to 36 weeks) to test the effect of salt restriction on endpoints such as death, cardiovascular events or CKD progression, changes in salt intake on blood pressure and other secondary risk factors were examined. Reducing salt by mean -73.51 mmol/day (95% CI -92.76 to -54.27), equivalent to 4.2 g or 1690 mg sodium/day, reduced systolic/diastolic blood pressure by -6.91/-3.91 mm Hg (95% CI -8.82 to -4.99/-4.80 to -3.02; 19 studies, 1405 participants; high certainty evidence). Albuminuria was reduced by 36% (95% CI 26 to 44) in six studies, five of which were carried out in people in the earlier stages of CKD (MD -0.44, 95% CI -0.58 to -0.30; 501 participants; high certainty evidence). The evidence is very uncertain about the effect of lower salt intake on weight, as the weight change observed (-1.32 kg, 95% CI -1.94 to -0.70; 12 studies, 759 participants) may have been due to fluid volume, lean tissue, or body fat. Lower salt intake may reduce extracellular fluid volume in the earlier stages of CKD (-0.87 L, 95% CI -1.17 to -0.58; 3 studies; 187 participants; low certainty evidence). The evidence is very uncertain about the effect of lower salt intake on reduction in antihypertensive dose (RR 2.45, 95% CI 0.98 to 6.08; 8 studies; 754 participants). Lower salt intake may lead to  symptomatic hypotension (RR 6.70, 95% CI 2.40 to 18.69; 6 studies; 678 participants; moderate certainty evidence). Data were sparse for other types of adverse events.

AUTHORS' CONCLUSIONS

We found high certainty evidence that salt reduction reduced blood pressure in people with CKD, and albuminuria in people with earlier stage CKD in the short-term. If such reductions could be maintained long-term, this effect may translate to clinically significant reductions in CKD progression and cardiovascular events. Research into the long-term effects of sodium-restricted diet for people with CKD is warranted.

Comparison of the effect of educational and self-management interventions on adherence to treatment in hemodialysis patients: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Adherence to fluid intake, diet, and drug management is very important in hemodialysis patients. Educational and self-management interventions are frequently used to improve adherence to treatment in hemodialysis patients.

OBJECTIVES

To synthesize a comparison of the effect of educational and self-management interventions on adherence to treatment in hemodialysis patients in randomized controlled trials.

METHODS

Systematic searches were conducted using 11 multidisciplinary databases in June 2020. The PRISMA checklist was used. The subgroup analysis was used to compare the effect of educational and self-management interventions on adherence to fluid intake, diet, and drug management.

RESULTS

In the included studies, educational interventions were performed ranging from 15 to 60 minutes, in 1-72 sessions. Self-management interventions were performed ranging from 10 to 120 minutes, in 1-84 sessions. The overall effect of educational interventions was small on adherence to fluid intake (P = .019, Hedges' g = -0.39), diet in serum phosphorus level (P = .001, Hedges' g = -0.35), drug management (P = .002, Hedges' g = -0.44), and not significant on adherence to diet in serum potassium level (P = .181). The overall effect of self-management interventions was small on adherence to fluid intake (P = .001, Hedges' g = -0.19) and diet in serum phosphorus level (P < .001, Hedges' g = -0.42). Additionally, the overall effect of self-management interventions was moderate on adherence to diet in serum potassium level (P = .002, Hedges' g = -0.75) and drug management (P < .001, Hedges' g = -0.55). There was no difference between the educational and self-management interventions on adherence to fluid intake, diet, and drug management (P > .05).

CONCLUSIONS

The analysis shows that educational and self-management interventions had a beneficial effect on adherence to fluid intake, diet, and drug management and no difference between these interventions. Therefore, these interventions can be used by healthcare professionals. It is also recommended that these interventions be well defined and transferable to routine clinical practice.

Pilot study to reduce interdialytic weight gain by provision of low-sodium, home-delivered meals in hemodialysis patients

INTRODUCTION

Patients with kidney failure undergoing maintenance hemodialysis (HD) therapy are routinely counseled to reduce dietary sodium intake to ameliorate sodium retention, volume overload, and hypertension. However, low-sodium diet trials in HD are sparse and indicate that dietary education and behavioral counseling are ineffective in reducing sodium intake. This study aimed to determine whether 4 weeks of low-sodium, home-delivered meals in HD patients reduces interdialytic weight gain (IDWG). Secondary outcomes included changes in dietary sodium intake, thirst, xerostomia, blood pressure, volume overload, and muscle sodium concentration.

METHODS

Twenty HD patients (55 ± 12 years, body mass index [BMI] 40.7 ± 16.6 kg/m² ) were enrolled in this study. Participants followed a usual (control) diet for the first 4 weeks followed by 4 weeks of three low-sodium, home-delivered meals per day. We measured IDWG, hydration status (bioimpedance), standardized blood pressure (BP), food intake (3-day dietary recall), and muscle sodium (magnetic resonance imaging) at baseline (0 M), after the 4-week period of usual diet (1 M), and after the meal intervention (2 M).

FINDINGS

The low-sodium meal intervention significantly reduced IDWG when compared to the control period (-0.82 ± 0.14 kg; 95% confidence interval, -0.55 to -1.08 kg; P < 0.001). There were also 1 month (1 M) to 2 month (2 M) reductions in dietary sodium intake (-1687 ± 297 mg; P < 0.001); thirst score (-4.4 ± 1.3; P = 0.003), xerostomia score (-6.7 ± 1.9; P = 0.002), SBP (-18.0 ± 3.6 mmHg; P < 0.001), DBP (-5.9 ± 2.0 mmHg; P = 0.008), and plasma phosphorus -1.55 ± 0.21 mg/dL; P = 0.005), as well as a 0 M to 2 M reduction in absolute volume overload (-1.08 ± 0.33 L; P = 0.025). However, there were no significant changes in serum or tissue sodium (all P > 0.05).

DISCUSSION

Low-sodium, home-meal delivery appears to be an effective method for improving volume control and blood pressure in HD patients. Future studies with larger sample sizes are needed to examine the long-term effects of home-delivered meals on these outcomes and to assess cost-effectiveness.

Thirst in patients on chronic hemodialysis: What do we know so far?

Thirst has been defined as "the sensation that leads animal's and human's actions toward the goal of finding and drinking water" or as "any drive that can motivate water intake, regardless of cause". Thirst, together with xerostomia, is the main cause of poor adherence to fluid restriction and of excessive intake of fluids in patients on chronic hemodialysis, and consequently of high interdialytic weight gain. Interdialytic weight gain (IDWG) should be lower than 4.0-4.5% of dry weight. Unfortunately, many patients have an IDWG greater than this value and some have IDWG of 10-20%. High IDWG is associated with a higher risk of all-cause and cardiovascular death and increased morbidity, such as ventricular hypertrophy and major adverse cardiac and cerebrovascular events. In addition, high IDWG leads to supplementary weekly dialysis sessions with consequent deterioration of quality of life and increased costs. Thus, the knowledge of thirst in patients on chronic hemodialysis is essential to prompt its adequate management to limit IDWG in the routine clinical practice. The present review aims to describe the physiology of thirst in patients on chronic hemodialysis, as well as the prevalence, its measures, the associated variables, the consequences, and the strategies for its reduction.

Dietary Daily Sodium Intake Lower than 1500 mg Is Associated with Inadequately Low Intake of Calorie, Protein, Iron, Zinc and Vitamin B1 in Patients on Chronic Hemodialysis

Background: To measure daily sodium intake in patients on chronic hemodialysis and to compare the intake of nutrients, minerals, trace elements, and vitamins in patients who had a daily sodium intake below or above the value of 1500 mg recommended by the American Heart Association. Methods: Dietary intake was recorded for 3 days by means of 3-day diet diaries in prevalent patients on chronic hemodialysis. Each patient was instructed by a dietitian on how to fill the diary, which was subsequently signed by a next of kin. Results: We studied 127 patients. Mean sodium intake (mg) was 1295.9 ± 812.3. Eighty-seven (68.5%) patients had a daily sodium intake <1500 mg (group 1) and 40 (31.5%) ≥ 1500 mg (group 2). Correlation between daily sodium intake and daily calorie intake was significant (r = 0.474 [0.327 to 0.599]; p < 0.0001). Daily calorie intake (kcal/kg/day) was lower in group 1 (21.1 ± 6.6; p = 0.0001) than in group 2 (27.1 ± 10.4). Correlation between daily sodium intake and daily protein intake was significant (r = 0.530 [0.392 to 0.644]; p < 0.0001). The daily protein intake (grams/kg/day) was lower in group 1 (0.823 ± 0.275; p = 0.0003) than in group 2 (1.061 ± 0.419). Daily intake of magnesium, copper, iron, zinc, and selenium was significantly lower in group 1 than in group 2. Daily intake of vitamin A, B2, B3, and C did not differ significantly between group 1 and group 2. Daily intake of vitamin B1 was significantly lower in group 1 than in group 2. Significantly lower was, in group 1 than in group 2, the percentage of patients within the target value with regard to intake of calories (11.5% vs. 37.5%; p = 0.001) and proteins (9.2% vs. 27.5%; p = 0.015) as well as of iron (23% vs. 45%; p = 0.020), zinc (13.8% vs. 53.8%; p = 0.008) and vitamin B1 (8.1% vs. 50%; p < 0.001). Conclusion: A low daily intake of sodium is associated with an inadequately low intake of calorie, proteins, minerals, trace elements, and vitamin B1. Nutritional counselling aimed to reduce the intake of sodium in patients on chronic hemodialysis should not disregard an adequate intake of macro- and micronutrients, otherwise the risk of malnutrition is high.

Information Technology-based Interventions for Health Care Support in Patients with Chronic Kidney Disease: A Systematic Review

Background: Self-management and support in managing therapeutic regimens is very important for patients with CKD. Information technology-based interventions are increasingly being used to support the self-management of patients with CKD. This study aimed to conduct a systematic review to evaluate information technology-based interventions in relation to the support of the health management of patients with CKD.Method: We conducted a systematic review using electronic databases (Scopus, Science Direct, ProQuest) limited to the last 8 years from 2010 to 2018 with the relevant keywords. The studies included used RCT, pilot and case-control methods focusing on patients with CKD stage 1-5 and that reported on at least one outcome from the health management of patients with CKD.Result: Out of the 7.852 studies taken, 13 studies fulfilled the inclusion criteria. The interventions in this systematic review are multifaceted, including smartphone/PDA (6/13), telematics devices (2/13), internet/web (3/13) and a combination of several interventions (2 studies). In total, 12 (92%) out of the 13 studies showed a positive outcome from the intervention, 7 studies showed improved outcomes in the clinical points, 3 studies had improved adherence and 2 studies improved knowledge.Conclusion: This evidence indicates the potential of IT-based interventions (i.e. smartphone/PDA, computer, internet/web, telematic device) to support the health management of patients with CKD. The variety of interventions in this systematic review requires further research on which interventions are best applied.

The relationship of volume overload and its control to hypertension in hemodialysis patients

Hypertension is highly prevalent and associated with poor clinical outcomes among individuals receiving maintenance hemodialysis (HD). Volume overload is a key modifiable contributor to hypertension and cardiovascular disease in the HD population. Despite their importance, assessment and treatment of volume overload and hypertension remain major clinical challenges and have substantial implications for both clinical outcomes and patient experiences of care. This review will summarize current data on the diagnosis, epidemiology, pathophysiology, and clinical consequences of hypertension and volume overload in HD patients. We will also identify priorities for future research studies.

eHealth interventions for people with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours.

OBJECTIVES

This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 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 Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies (39 studies) were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 studies (2%) in transplant candidates We identified six different eHealth modalities including: Telehealth; mobile or tablet application; text or email messages; electronic monitors; internet/websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies).Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I² = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I² = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness (interdialytic weight gain) and high or unclear risk of bias and imprecision (dietary sodium intake). Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision.

AUTHORS' CONCLUSIONS

eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core (minimum) data set to enable meaningful evaluation of the literature.

Targeted, structured text messaging to improve dietary and lifestyle behaviours for people on maintenance haemodialysis (KIDNEYTEXT): study protocol for a randomised controlled trial

INTRODUCTION

Managing nutrition is critical for reducing morbidity and mortality in patients on haemodialysis but adherence to the complex dietary restrictions remains problematic. Innovative interventions to enhance the delivery of nutritional care are needed. The aim of this phase II trial is to evaluate the feasibility and effectiveness of a targeted mobile phone text messaging system to improve dietary and lifestyle behaviours in patients on long-term haemodialysis.

METHODS AND ANALYSIS

Single-blinded randomised controlled trial with 6 months of follow-up in 130 patients on haemodialysis who will be randomised to either standard care or KIDNEYTEXT. The KIDNEYTEXT intervention group will receive three text messages per week for 6 months. The text messages provide customised dietary information and advice based on renal dietary guidelines and general healthy eating dietary guidelines, and motivation and support to improve behaviours. The primary outcome is feasibility including recruitment rate, drop-out rate, adherence to renal dietary recommendations, participant satisfaction and a process evaluation using semistructured interviews with a subset of purposively sampled participants. Secondary and exploratory outcomes include a range of clinical and behavioural outcomes and a healthcare utilisation cost analysis will be undertaken.

ETHICS AND DISSEMINATION

The study has been approved by the Western Sydney Local Health District Human Research Ethics Committee-Westmead. Results will be presented at scientific meetings and published in peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ACTRN12617001084370; Pre-results.

Quantifying the Time Used for Renal Dietitian's Responsibilities: A Pilot Study

OBJECTIVE

The purpose of this study was to quantify how dialysis dietitians spend their time and whether the activities that were most frequent varied based on the ratio of patient to full-time equivalent (FTE) dietitian.

METHODS

This study is a cross-sectional, observational, time-and-motion study carried out using the Work Activity Measurement by Activity Timing software/method for time recording. This study was carried out in 14 dialysis centers in and around Cleveland, Ohio. Fourteen registered dietitian nutritionists participated in this study. The mean time/experience of these nutritionists in dietetics was 26.6 ± 8.5 years. Percent of time in direct care (e.g., patient interaction) versus indirect care (e.g., documentation and plans of care, professional communication) versus other responsibilities (e.g., administrative work, education of self or others).

RESULTS

The mean number of tasks recorded per 3-hour observation session was 38.3 ± 14.0, including 18.5 ± 7.7 indirect care tasks, 7.7 ± 6.2 direct care tasks, and 9.7 ± 5.4 other tasks. The mean number of unique patients seen per observation session was 6.9 ± 5.4; the mean direct care time per patient encounter was 6.95 ± 4.05 minutes. Indirect care took the highest proportion of observed time, 56.0 ± 22.2%, followed by direct care, 24.9 ± 18.8%. Increasing the ratio of patient to FTE had a moderate negative correlation with the percent of time spent in direct patient care (r = -0.35, P = .21), but there was no relationship between the ratio of patient to FTE and direct care time per patient (r = 0.02, P = .94).

CONCLUSION

About 25% of dietitians' time was available for direct patient care. This is much less than that reported in previous studies and may not be sufficient to improve the nutritional status. Limitations of our study include a small sample size from a single region. Further work is needed to understand the balance of responsibilities among renal dietitians and their impact on patient outcomes.

Determinants and the Role of Self-Efficacy in a Sodium-Reduction Trial in Hemodialysis Patients

OBJECTIVE

This study was to assess the impact of baseline dietary self-efficacy on the effect of a dietary intervention to reduce sodium intake in patients undergoing hemodialysis (HD) and to identify determinants of low dietary self-efficacy.

METHODS

This is a post hoc analysis of the BalanceWise study, a randomized controlled trial that aimed to reduce dietary sodium intake in HD patients recruited from 17 dialysis centers in Pennsylvania. The main outcome measures include dietary self-efficacy and reported dietary sodium density. Analysis of variance with post hoc group-wise comparison was used to examine the effect of baseline dietary self-efficacy on changes in reported sodium density in the intervention and control groups at 8 and 16 weeks. Chi-square test, independent t tests, or Wilcoxon rank-sum tests were used to identify determinants of low dietary self-efficacy.

RESULTS

The interaction between dietary self-efficacy and the impact of the intervention on changes in reported dietary sodium density approached significance at 8 and 16 weeks (P interaction = 0.051 and 0.06, respectively). Younger age and perceived income inadequacy were significantly associated with low self-efficacy in patients undergoing HD.

CONCLUSION

The benefits of dietary interventions designed to improve self-efficacy may differ by the baseline self-efficacy status. This may be particularly important for HD patients who are younger and report inadequate income as they had lower dietary self-efficacy.

Experiences and Perspectives of Dietary Management Among Patients on Hemodialysis: An Interview Study

OBJECTIVES

Diet and fluid management can reduce mortality, serious comorbidities, and debilitating symptoms in patients on hemodialysis, but restrictions may also be a major burden, and nonadherence remains high. We aimed to describe the perspectives and experiences of patients on hemodialysis regarding their dietary management to understand both facilitators and barriers to adherence and to identify strategies to improve care.

DESIGN AND METHODS

Semi-structured interviews were conducted with 35 people on maintenance hemodialysis from six dialysis units in New South Wales, Australia. Transcripts were thematically analyzed using principles of grounded theory.

RESULTS

We identified 5 major themes. Two themes reflect barriers to dietary change: exacerbating disruption (adding to treatment burden, contradicting healthy eating, confused by fragmented advice, conflicting cultural norms, changing appetite and palate, isolation from family and friends) and losing control (crises derailing discipline, frustrated by failure, combating bodily need for hydration). Three themes represent enablers for dietary change: attaining health benefits (avoiding medical catastrophes, enhancing benefits of dialysis, alleviating and managing symptoms, improving health), achieving treatment goals (building familiarity and acceptance, flexibility and moderation, taking personal responsibility), and succeeding withsupport (leaning on family for strength, trusting expert guidance, empowered with flexible and practical advice, relying on reminders and cues, motivation through shared experience).

CONCLUSIONS

Patients on hemodialysis believe dietary control helps to reduce symptom burden and enhance general health and well-being, but competing medical and social issues coupled with contradictory and/or irrelevant dietary advice prevents them from implementing diet and fluid restrictions. Interventions involving collaborative multidisciplinary care including clinicians with dietetic expertise, and consistent information that addresses cultural and personal circumstances, may support adherence to dietary recommendations and improve outcomes.

Impact of salt reduction in meals consumed during hemodialysis sessions on interdialytic weight gain and hemodynamic stability

INTRODUCTION

Patients on hemodialysis (HD) are advised to limit daily water- and salt intake to reduce interdialytic weight gain (IDWG). To counterbalance protein-losses, protein-rich meals are sometimes provided during HD sessions, but their salt content is not always taken into account. The aim of this study was to assess the influence of a lower salt content of meals provided during HD sessions on IDWG, blood pressure (BP), and hemodynamic stability during dialysis.

METHODS

This monocentric, interventional study was proposed to all the patients treated with three weekly HD sessions. The first two months of the study (high salt period), the patients continued to receive one sandwich containing 2.4 g of salt per session. Then, we reduced its salt content from 2.4 to 1.4 g, and patients received this "low-salt sandwich" at each dialysis session for four months. The mean values of IDWG, BP, and dry weight of the first two months were compared with those collected during the low salt periods (2-6 months).

FINDINGS

Forty out of 76 patients who initially agreed to participate were free of hospitalization, transplantation, and transfer to another center or death during the study period and were included in the final analysis (35% women). Median age was 63 years (range 28-90), 22.5% had a residual diuresis > 0.5 L/day. IDWG baseline decreased from 2.17 ± 0.98 to 2.03 ± 1 kg (P = 0.001) two months and to 2.09 ± 1.01 kg (P = 0.009) four months after we had lowered the salt content of the sandwich. The number of symptomatic intradialytic hypotension was also reduced (6.1% vs., respectively, 3.2% and 3.3% of HD sessions; P = 0.004).

DISCUSSION

IDWG was reduced and hemodynamic stability improved after the reduction of the salt content of perdialytic meals. This suggests that salt consumed during HD matters and might influence salt and water intake outside the dialysis unit.

Features and Effects of Information Technology-Based Interventions to Improve Self-Management in Chronic Kidney Disease Patients: a Systematic Review of the Literature

Slowing down the progression of chronic kidney disease (CKD) and its adverse health outcomes requires the patient's self-management and attention to treatment recommendations. Information technology (IT)-based interventions are increasingly being used to support self-management in patients with chronic diseases such as CKD. We conducted a systematic review of randomized controlled trials (RCTs) to assess the features and effects of IT-based interventions on self-management outcomes of CKD patients. A comprehensive search was conducted in Medline, Scopus, and the Cochrane Library to identify relevant papers that were published until May 2016. RCT Studies that assessed at least one automated IT tool in patients with CKD stages 1 to 5, and reported at least one self-management outcome were included. Studies were appraised for quality using the Cochrane Risk of Bias assessment tool. Out of 12,215 papers retrieved, eight study met the inclusion criteria. Interventions were delivered via smartphones/personal digital assistants (PDAs) (three studies), wearable devices (three studies), computerized systems (one study), and multiple component (one study). The studies assessed 15 outcomes, including eight clinical outcomes and seven process of care outcomes. In 12 (80%) of the 15 outcomes, the studies had revealed the effects of the interventions as statistically significant positive. These positive effects were observed in 75% of the clinical outcomes and 86% of the process of care outcomes. The evidence indicates the potential of IT-based interventions (i.e. smartphones/PDAs, wearable devices, and computerized systems) in self-management outcomes (clinical and process of care outcomes) of CKD patients.

Nutrient Non-equivalence: Does Restricting High-Potassium Plant Foods Help to Prevent Hyperkalemia in Hemodialysis Patients?

Hemodialysis patients are often advised to limit their intake of high-potassium foods to help manage hyperkalemia. However, the benefits of this practice are entirely theoretical and not supported by rigorous randomized controlled trials. The hypothesis that potassium restriction is useful is based on the assumption that different sources of dietary potassium are therapeutically equivalent. In fact, animal and plant sources of potassium may differ in their potential to contribute to hyperkalemia. In this commentary, we summarize the historical research basis for limiting high-potassium foods. Ultimately, we conclude that this approach is not evidence-based and may actually present harm to patients. However, given the uncertainty arising from the paucity of conclusive data, we agree that until the appropriate intervention studies are conducted, practitioners should continue to advise restriction of high-potassium foods.

Modified Nutritional Recommendations to Improve Dietary Patterns and Outcomes in Hemodialysis Patients

The renal diet has traditionally been regarded as one of the most complex medical nutrition therapies to teach, understand, and implement. Specifically, patients are instructed to limit fruits, vegetables, nuts, legumes, dairy, and whole grains because of both phosphorus and potassium concerns. Furthermore, hemodialysis patients are often encouraged to decrease fluid intake to control interdialytic weight gain. These restrictions can result in frustration, lack of autonomy, and the perception that there is nothing left to eat. It is possible that the traditional renal diet may be liberalized, with a focus on whole foods low in sodium and phosphorus additives, to afford patients greater choices and ultimately improved outcomes. Therefore, the objective of this review is to concisely assess the evidence in support of a renal diet focused primarily on reducing the intake of sodium and inorganic phosphorus. Finally, the limited evidence for restrictions on dietary potassium intake is summarized.