Haemodialysis prescription, adherence and nutritional indicators in five European countries: results from the Dialysis Outcomes and Practice Patterns Study (DOPPS)

Dietary Intake and Nutritional Status in Diabetic and Nondiabetic Patients With Chronic Kidney Disease Stage 4-5 (NutriDiab Study)

OBJECTIVES

The aim of the present study was to assess the dietary intake and nutritional status of patients with chronic kidney disease (CKD) stage 4-5 according to the presence of diabetes.

METHODS

This observational and cross-sectional study included adult patients with CKD stage 4-5 referred to a nephrology unit, between October 2018 and March 2019. Daily dietary intake was evaluated by 24-hour dietary inquiry and urine excretion. Nutritional status was assessed by measuring body composition using bioimpedance analysis and muscle function using handgrip strength. Undernutrition was considered using the protein energy wasting score.

RESULTS

A total of 75 CKD patients were included, 36 (48%) of whom had diabetes; median age (interquartile range) was 71 (60-80) years. The median weight-adjusted dietary energy intake (DEI) was 22.6 (19.1-28.2) kcal/kg/day and the mean weight-adjusted dietary protein intake (DPI) was 0.86 ± 0.19 g/kg/day. There was no significant difference in DEI and DPI between patients with diabetes and those without, except for weight-adjusted DPI which was significantly lower in diabetic patients (P = .022). In univariate analysis, diabetes was associated with weight-adjusted DPI (coefficient [95% confidence interval] -0.237 [-0.446; -0.004] kcal/kg/day; P = .040), but this association did not remain significant in multivariate analysis. Nutritional status did not differ significantly between diabetic and nondiabetic patients except for lean tissue mass, which was lower in diabetic patients (P = .046). The proportion of patients with protein energy wasting was not significantly different between diabetic and nondiabetic patients (13.9% vs. 10.2%, respectively).

CONCLUSIONS

In the present cohort, DPI and DEI were not significantly different between diabetic and nondiabetic CKD patients. Diabetes was not found to be associated with dietary intakes in CKD stage 4-5 patients.

Dialysis capacity and nutrition care across Bangladesh: A situational assessment

Hemodialysis (HD) is a treatment for ensuring the survival of end-stage kidney disease (ESKD) patients, and nutrition care is integral to their management. We sent questionnaires to evaluate the total dialysis service capacity and nutrition services across all dialysis facilities (DF) in Bangladesh, with responses from 149 out of 166 active DFs. Survey results revealed that 49.7% of DFs operated two shifts, and 42.3% operated three shifts daily, with 74.5% holding between one and ten dialysis machines. Sixty-three percent of DFs served between one and 25 patients per week, and 77% of patients received twice-weekly dialysis. The average cost for first-time dialysis was 2800 BDT per session (range: 2500-3000 BDT), but it was lower if reused dialyzers were used (2100 BDT, range: 1700-2800 BDT). Nutritionists were available in only 21% of the DFs. Parameters related to nutritional health screening (serum albumin, BMI, MIS-malnutrition inflammation assessment, and dietary intakes) were carried out in 37.6%, 23.5%, 2%, and 2% of the DFs, respectively, only if recommended by physicians. Nutrition education, if recommended, was provided in 68.5% of DFs, but only in 17.6% of them were these delivered by nutritionists. The recommendation for using renal-specific oral nutrition supplements (ONS) is not a familiar practice in Bangladeshi DFs and, therefore, was scarcely recommended. Dialysis capacity across Bangladesh is inadequate to meet current or projected needs and nutrition education and support across the DFs to benefit improving patients' quality of life is also inadequate.

Optimizing Nutrition in Renal Patients: Effects of a Low-Protein Diet Supplemented With Ketoacids

Background Chronic kidney disease (CKD) is a non-communicable disease; it is a major cause of morbidity and mortality in Nigeria as the incidence has been increasing in Nigeria over the last few years. A low-protein diet supplemented with ketoacids has been duly documented to reduce the malnutrition associated with CKD as well as improve estimated glomeruli filtration rate while delaying the onset of dialysis in predialysis CKD patients. Objective The aim of this study was to determine the effects of a low-protein diet supplemented with ketoacids compared to a conventional low protein on nutritional indices in predialysis CKD patients. Methods and materials A randomized controlled trial with a total of 60 participants was conducted at Delta State University Teaching Hospital (DELSUTH), Oghara, Nigeria. Participants were patients older than 18 years with CKD stage 3-5 who were not on dialysis. They were recruited and randomized into the intervention group (low-protein diet supplemented with ketoacids) with 30 participants and the non-intervention group (low protein with placebo) with 30 participants. The mean outcome was changed in the nutritional indices from baseline till the end of the study. Results A total of 60 patients were randomly allocated to receive a low-protein diet supplemented with ketoacids (n=30) or control (n=30). All participants were included in the analysis of all outcomes. The mean change score in serum total protein, albumin, and triglycerides between the intervention and non-intervention groups were 1.1±1.1 g/dL vs 0.1±1.1 g/dL (p<0.001), 0.2±0.9 g/dL vs -0.3±0.8 g/dL (p<0.001), and 3.0±3.5 g/dL vs 1.8±3.7 g/dL, respectively. Conclusion and recommendation The use of low-protein diet supplemented with ketoacids improved the anthropometric and nutritional indices in patients with stage 3-5 CKD.

Factors related to treatment adherence behaviors among old-age hemodialysis patients in Hamadan, Iran: the application of the extended theory of planned behavior during Covid-19 pandemic

Purpose

This study aimed to identify the factors related to treatment adherence behaviors among old-age hemodialysis patients in Hamadan based on the Extended Theory of Planned Behavior (ETPB) during the covid-19 pandemic.

Methods

This cross-sectional study was conducted from January to March 2021 in Hamadan, Iran. 191 hemodialysis patients were recruited who were referred to hemodialysis centers via the census method. Data were collected by a questionnaire containing items on socio-demographic information, End-Stage Renal Disease Adherence (ESRD-Adherence) Questionnaire, and ETPB constructs scale. Data analysis was performed using descriptive statistics and structural equation modeling.

Results

The mean (SD) age of participants was 62.49 (10.66). Also, the mean (SD) hemodialysis vintage/Month of them was 36.56 (43.34). Moreover, Treatment Adherence Behaviors are associated with education level, sex, and marital status (p < 0.001). Besides, Perceive Behavior Control (β = 0.414, t-value = 3.810) associated with intention. Also, intention (β = 0.158, t-value = 1.976) was associated to adherence behaviors. No significant associations were observed between positive attitudes, subjective norms, a perceived threat with intention, and adherence behaviors. The model explained about 54% of the variance of adherence behaviors. Finally, the goodness of fit index of 0.78, indicating the model good fit.

Conclusion

The present study demonstrates that some of the ETPB constructs such as perceived behavior control and intention are useful to improve adherence among the oldest hemodialysis patients. Also. This framework is revealed alongside the theory of planned behavior (TPB) applicable in the treatment adherence of old-age hemodialysis patients.

African Americans' Hemodialysis Treatment Adherence Data Assessment and Presentation: A Precision-Based Paradigm Shift to Support Quality Improvement Activities

RATIONALE & OBJECTIVE

Thrice-weekly hemodialysis can result in adequate urea clearance; however, the morbidity and mortality rates of patients treated with maintenance dialysis remain unacceptably high, partly because of nonadherence. African Americans have a higher prevalence of kidney failure treated with dialysis, greater dialysis nonadherence, and higher odds of hospitalization. We hypothesized that more precise ways of assessing dialysis treatment adherence will reflect the severity of nonadherence, distinguish patterns of nonadherence, and inform the design of personalized behavioral interventions.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

African American patients receiving hemodialysis for >90 days.

EXPOSURE

Hemodialysis.

OUTCOME

Dialysis adherence.

ANALYTICAL APPROACH

Dialysis attendance data were displayed using a dot plot, categorized based on missed and shortened treatments, and examined for patterns. Descriptive characteristics were reported. In an exploratory analysis, associations between dialysis treatment adherence and participant characteristics were evaluated using ordinary least squares regression. An analysis was performed using missed minutes of dialysis and current metrics for measuring dialysis treatment adherence (ie, missed and shortened treatments).

RESULTS

Among 113 African American patients treated with dialysis, 47% were men; the median age was 57 years (interquartile range, 46-70 years), and the median dialysis vintage was 54 months (interquartile range, 22-90 months). With rows ordered based on the total missed minutes of dialysis, the dot plot displayed a decreasing gradient in the severity of nonadherence, with novel dialysis treatment adherence categories termed as follows: consistent underdialysis, inconsistent dialysis, and consistent dialysis. Distinct patterns of nonadherence and heterogeneity emerged within these categories. Older age was consistently associated with better adherence, as determined by the analyses performed using the total missed minutes of dialysis as well as missed and shortened treatments.

LIMITATIONS

The study findings, although replicable and paradigm-shifting, might be limited by the short timeline, focus on adherence data specific to African American patients treated with dialysis, and restriction to dialysis units affiliated with 1 academic center.

CONCLUSIONS

This study presents more precise and novel ways of measuring and displaying dialysis treatment adherence. The findings introduce a more personalized approach for evaluating actual dialysis uptake. Identification of unique patterns of adherence behavior is important to inform the design of effective behavioral interventions and improve outcomes for vulnerable African American patients treated with dialysis.

Improvements in six aspects of quality of care of incident hemodialysis patients - a real-world experience

Background

The transition from chronic kidney disease stage 5 to initiation of hemodialysis has gained increased attention in recent years as this period is one of high risk for patients with an annual mortality rate exceeding 20%. Morbidity and mortality in incident hemodialysis patients are partially attributed to failure to attain guideline-based targets. This study focuses on improvements in six aspects of quality of dialysis care (adequacy, anemia, nutrition, chronic kidney disease-mineral bone disorder (CKD-MBD), blood pressure and vascular access) aligning with KDIGO guidelines, during the first 6 months of hemodialysis.

Methods

We analyzed patient demographics, practice patterns and laboratory data in all 3 462 patients (mean age 65.9 years, 41% females) on hemodialysis (incident <90 days on hemodialysis, n=603, prevalent ≥90 days on hemodialysis, mean 55 months, n=2 859) from all 56 DaVita centers in Poland (51 centers) and Portugal (5 centers). 80% of patients had hemodialysis and 20% hemodiafiltration. Statistical analyses included unpaired and paired Students t-test, Chi-2 analyses, McNemar test and logistic regression analysis.

Results

Incident patients had lower Kt/V (1.4 vs 1.7, p<0.001), lower serum albumin (37 vs 40 g/l, p=0.001), lower Hb (9.9 vs 11.0 g/dl, p<0.001), lower TSAT (26 vs 31%, p<0.001), lower iPTH (372 vs 496 pg/ml, p<0.001), more often a central venous catheter (68 vs 26%, p<0.001), less often an AV fistula (34 vs 70 %, p<0.001) compared with all prevalent patients. Significantly more prevalent patients achieved international treatment targets.

Improvements in quality of care was also analyzed in a subgroup of 258 incident patients who were followed prospectively for 6 months. We observed significant improvements in Kt/V (p<0.001), albumin (p<0.001), Hb (p<0.001) transferrin saturation (TSAT, p<0.001), iPTH (p=0.005) and an increased use of AV fistula (p<0.001). Furthermore, logistic regression analyses identified treatment time and TSAT as major factors influencing the attainment of adequacy and anemia treatment targets.

Conclusion

This large real-world European multicenter analysis of representative incident hemodialysis patients indicates that the use of medical protocols and medical targets assures significant improvements in quality of care, which may correspond to better outcomes. A selection bias of survivors with less comorbidities in prevalent patients may have influenced the results.

Longitudinal Causal Effects of Normalized Protein Catabolic Rate on All-Cause Mortality in Patients With End-Stage Renal Disease: Adjusting for Time-Varying Confounders Using the G-Estimation Method

In this study, we aimed to estimate the causal effect of normalized protein catabolic rate (nPCR) on mortality among end-stage renal disease (ESRD) patients in the presence of time-varying confounding affected by prior exposure using g-estimation. Information about 553 ESRD patients was retrospectively collected over an 8-year period (2011-2019) from hemodialysis facilities in Kerman, Iran. nPCR was dichotomized as <1.2 g/kg/day versus ≥1.2 g/kg/day. Then a standard time-varying accelerated failure time (AFT) Weibull model was built, and results were compared with those generated by g-estimation. After appropriate adjustment for time-varying confounders, weighted g-estimation yielded 78% shorter survival time (95% confidence interval (95% CI): -81, -73) among patients with a continuous nPCR <1.2 g/kg/day than among those who had nPCR ≥1.2 g/kg/day during follow-up, though it was 18% (95% CI: -57, 54) in the Weibull model. Moreover, hazard ratio estimates of 4.56 (95% CI: 3.69, 5.37) and 1.20 (95% CI: 0.66, 2.17) were obtained via weighted g-estimation and the Weibull model, respectively. G-estimation indicated that inadequate dietary protein intake characterized by nPCR increases all-cause mortality among ESRD patients, but the Weibull model provided an effect estimate that was substantially biased toward the null.

Management of acute intradialytic cardiovascular complications: Updated overview (Review)

An increasing number of patients require renal replacement therapy through dialysis and renal transplantation. Chronic kidney disease (CKD) affects a large percentage of the world's population and has evolved into a major public health concern. Diabetes mellitus, high blood pressure and a family history of kidney failure are all major risk factors for CKD. Patients in advanced stages of CKD have varying degrees of cardiovascular damage. Comorbidities of these patients, include, on the one hand, hypertension, hyperlipidemia, hyperglycemia, hyperuricemia and, on the other hand, the presence of mineral-bone disorders associated with CKD and chronic inflammation, which contribute to cardiovascular involvement. Acute complications occur quite frequently during dialysis. Among these, the most important are cardiovascular complications, which influence the morbidity and mortality rates of this group of patients. Chronic hemodialysis patients manifest acute cardiovascular complications such as intradialytic hypotension, intradialytic hypertension, arrhythmias, acute coronary syndromes and sudden death. Thus, proper management is extremely important.

Comparison of nutritional and hydration status in patients undergoing twice and thrice-weekly hemodialysis: a silent drama in developing countries

PURPOSE

In low and middle- income countries, due to lack of financial resources, the number of patients receiving one or two hemodialysis (HD) sessions a week has increased, leading to a large number of complications. Protein-energy wasting (PEW) and overhydration (OH) are common complications; nevertheless, the evidence regarding the nutritional status of patients receiving 2 and 3 weekly dialysis sessions is scarce. Thus, our objective was to compare the nutritional and hydration status of patients with two and three HD sessions. Secondarily, we aimed to compare hospitalizations, infectious complications and mortality within the following 6 months after the initial assessment.

METHODS

Forty-four patients in a 3 weekly session scheme and 44 dialyzed twice a week were included. Anthropometrical, biochemical, dietary and impedance measurements were performed. Malnutrition Inflammation Score (MIS) and PEW score were applied. Number of hospitalizations, infectious complications and mortality during the 6 months following the evaluation were recorded.

RESULTS

Prevalence of moderate/severe undernutrition (63.6% vs 36.4%, p < 0.006) and prevalence of OH (90.9% vs 77.3%, p < 0.001) were significantly higher in the twice-weekly sessions group compared to the 3 weekly sessions. The twice a week session group showed a 3.7-fold (OR 3.7, 95% CI 1.3-10.5, p = 0.01), a 2.5-fold (OR 2.4, 95% CI 0.9-6.6, p = 0.01), a 4.5-fold (OR 4.5, 95% CI 1.0-20.2, p < 0.05), a 8.3-fold (HR 8.3, 95% CI 2.4-28.2, p = 0.001) and a 11.6-fold (HR 11.6, 95% CI 2.4-54.0, p = 0.002) increased odds of developing undernutrition, PEW, OH, being hospitalized or death, respectively, compared to those who received three sessions per week.

CONCLUSIONS

Twice weekly hemodialysis scheme is associated with higher odds of moderate or severe undernutrition, PEW, OH status, hospitalization and mortality compared to a thrice-weekly hemodialysis scheme.

Enhancement of Adherence to Therapeutic and Lifestyle Recommendations Among Hemodialysis Patients: An Umbrella Review of Interventional Strategies

Objective

To systematically retrieve and condense the best possible evidence on the successful interventions that targeted enhancement of therapeutic and lifestyle recommendations adherence in hemodialysis patients (HDPs).

Design

An umbrella review of interventional studies.

Data Sources

A comprehensive search of the Cochrane Database of Systematic Reviews, Ovid, PubMed, Scopus, EMBASE and Web of science databases to identify relevant publications in 2000–2018 (June) timeframe.

Study Selection

Two reviewers independently applied inclusion criteria to select potential systematic reviews assessing the successful interventions that targeted enhancement of therapeutic and lifestyle recommendations adherence in HDPs. Data were summarized for information about the first author(s)’ names, year of publication, type(s) of the intervention and output variables, main findings and also the applied quality appraisal tools in the retrieved research evidence.

Data Extraction

Eligible studies were selected and data were extracted independently by two reviewers. The Joanna Briggs Institute (JBI)’s critical appraisal tool for systematic reviews was used to assess the quality of the identified publications, and discrepancies were resolved by consensus with a third reviewer.

Data Synthesis

Thirteen systematic reviews (12 solely systematic reviews and 1 systematic review with meta-analyses) were eligible to be enrolled in the study. The range of interventions that had been reported to boost therapeutic and lifestyle recommendations adherence in HDPs’ included psycho-educational programs, physical activity enhancement initiatives, information technology (IT)-based interventions and aromatherapy. Depression, diet biomarkers and interdialytic weight gain (IDWG) were among the myriad of output variables that had been measured as proxies to assess impacts of the implemented interventions. Psycho-educational interventions were among the prevalent initiatives to boost therapeutic and lifestyle recommendations adherence among the HDPs.

Conclusion

This umbrella review revealed that various intervention approaches and strategies can be used for HDPs' better therapeutic and lifestyle recommendations adherence with considerable methodological heterogeneity. The pinpointed research evidence is also supporting application of multifaceted interventional modalities to reach an improved acquiescence form the patients’ side and their families. Further studies are recommended to address the interactions across various interventions in discordant socio-cultural contexts.

Depressive symptoms and dietary non-adherence among end stage renal disease patients undergoing hemodialysis therapy: systematic review

Background

Research suggests that patients with end stage renal disease undergoing hemodialysis have a higher rate of depression and dietary non adherence leading to hospitalization and mortality. The purpose of this review was to synthesize the quantitative evidence on the relationship between depressive symptoms and dietary non adherence among end stage renal disease (ESRD) patients receiving hemodialysis.

Methods

A systematic review was undertaken. Three electronic databases were searched including PubMed, CINHAL and Web of Science. Only quantitative studies published between 2001 and 2016 were included in the review.

Result

A total of 141 publications were reviewed during the search process and 28 articles that fulfilled the inclusion criteria were included in the review. Eleven studies (39.3%) reported on the prevalence of depressive symptoms or depression and its effect on patient outcomes. Ten studies (35.7%) focused on dietary adherence/non adherence in patients with ESRD and the remaining seven (25%) articles were descriptive studies on the relationship between depressive symptoms and dietary non adherence in patients with ESRD receiving hemodialysis. The prevalence of depressive symptoms and dietary non adherence ranged as 6–83.49% and from 41.1–98.3% respectively. Decreased quality of life & increased morbidity and mortality were positively associated with depressive symptoms. Other factors including urea, hemoglobin, creatinine and serum albumin had also association with depressive symptoms. Regarding dietary non adherence, age, social support, educational status, behavioral control and positive attitudes are important factors in ESRD patients receiving hemodialysis. Having depressive symptoms is more likely to increase dietary non adherence.

Conclusion

Depressive symptoms and dietary non adherence were highly prevalent in patients with end stage renal disease receiving hemodialysis therapy. Nearly all of the articles that examined the relationship between depressive symptoms and dietary non adherence found a significant association. Future research using experimental or longitudinal design and gold standard measures with established cut-points is needed to further explain the relationship.

A potential barrier to adherence? Memory for future intentions is impaired in hemodialysis patients

INTRODUCTION

End-stage renal disease (ESRD) has been associated with a range of cognitive deficits, including impaired retrospective memory and attention. Prospective memory (PM) is memory for future intentions, such as remembering to take medication on time. Prospective memory has not been examined in any ESRD patients; yet, the implications upon diet and medication management could potentially have detrimental effects on patient welfare. This is the first study to examine PM in ESRD patients being treated with hemodialysis (HD).

METHODS

Hemodialysis patients (n = 18) were compared with age-matched and education-matched controls (n = 18) on a boardgame task that emulates a typical week of activities (i.e., grocery shopping, meetings with friends), requiring the participant to remember a series of upcoming tasks. Other measures were also examined, including general cognitive decline, measures of independent living, IQ, and mood.

FINDINGS

Patients recalled significantly fewer upcoming events than the control group, suggesting an impairment of PM. No significant relationship was found between PM performance and any other measures, suggesting the difference between groups is likely due to the effects of ESRD, HD treatment, or some associated comorbidity.

DISCUSSION

This is the first study to demonstrate a PM deficit in patients undergoing HD treatment. This finding contributes to the current knowledge of the cognitive profile of patients undergoing HD while also highlighting the implications that a PM deficit may have on patient quality of life. The finding may go some way to explaining variances in patients' ability to monitor and adhere to medication and dietary regimes and, ultimately, to live independently. The study also highlights the necessity of viewing treatment for ESRD as a holistic process to maximize patient well-being.

Adherence Behavior in Subjects on Hemodialysis Is Not a Clear Predictor of Posttransplantation Adherence

Introduction

Nonadherence is common in both hemodialysis (HD) and kidney transplant recipients and is a major risk factor for poor clinical outcomes. This retrospective study explored whether nonadherent HD patients become nonadherent transplant recipients.

Methods

Data were collected for 88 patients from the electronic patient system at a subregional renal unit about adherence to HD regimens in the 6 months before transplantation, and for 1 year posttransplantation following return transfer to the posttransplantation clinic from the transplanting center. Pretransplantation definitions of nonadherence included whether the patients: on average, shortened their dialysis prescription by >10 minutes; shortened it by >15 minutes; missed 2 or more HD sessions; and had mean serum phosphate levels >1.8mmol/l. Posttransplantation definitions of nonadherence included mean tacrolimus levels outside 5 to 10 ng/ml; and missed 1 or more posttransplantation clinic appointments.

Results

Nonadherence ranged from 25% to 42% pretransplantation and from 15.9% to 22.7% posttransplantation, depending on how it was operationalized. There was little relationship between pretransplantation data and posttransplantation adherence, with the exception of a significant relationship between pretransplantation phosphate and posttransplantation clinic attendance. Patients who had missed 1 or more transplant clinic appointments had higher mean pretransplantation phosphate levels. Nonadherent patients with high phosphate levels pretransplantation and missed clinic appointments posttransplantation were significantly younger.

Conclusion

Our findings provide little support for the likelihood of a strong direct relationship between pre and posttransplantation behaviors. The findings require confirmation and further research to assess whether interventions in relation to pretransplantation adherence may enhance adherence posttransplantation and improve outcomes.

Criteria for classification of protein-energy wasting in dialysis patients: impact on prevalence

Malnutrition is highly prevalent in dialysis patients and associated with poor outcomes. In 2008, protein-energy wasting (PEW) was coined by the International Society of Renal Nutrition and Metabolism (ISRNM), as a single pathological condition in which undernourishment and hypercatabolism converge. In 2014, a new simplified score was described using serum creatinine adjusted for body surface area (sCr/BSA) to replace a reduction of muscle mass over time in the muscle wasting category. We have now compared PEW-ISRNM 2008 and PEW-score 2014 to evaluate the prevalence of PEW and the risk of death in 109 haemodialysis patients. This was a retrospective analysis of cross sectional data with a median prospective follow-up of 20 months. The prevalence of PEW was 41 % for PEW-ISRNM 2008 and 63 % for PEW-score 2014 (P &lt;0·002). Using PEW-score 2014: twenty-nine patients (27 %) had severe malnutrition (PEW-score 2014 0-1) and forty (37 %) with moderate malnutrition (score 2). Additionally, thirty-three (30 %) patients had mild wasting and only seven patients (6 %) presented a normal nutritional status. sCr/BSA correlated with lean total mass (R 0·46. P&lt;0·001). A diagnosis of PEW according to PEW-score 2014, but not according to PEW-ISRNM 2008, was significantly associated with short-term mortality (P=0·0349) in univariate but not in multivariate analysis (P=0·069). In conclusion, the new PEW-score 2014 incorporating sCr/BSA identifies a higher number of dialysis PEW patients than PEW-ISRNM 2008. Whereas PEW-score-2014 provides timelier and therefore more clinically relevant information, its association with early mortality needs to be confirmed in larger studies.

Phosphorus nutritional knowledge among dialysis health care providers and patients: A multicenter observational study

BACKGROUND-AIMS

Phosphorus nutritional knowledge level of hemodialysis patients and renal nurses has been found to be low, while respective knowledge of nephrologists has not been studied yet. There are equivocal results regarding the association of phosphorus nutritional knowledge level and serum phosphorus values. The aim of this study was to assess phosphorus nutritional knowledge of hemodialysis patients, nephrologists and renal nurses and seek potential interventions to improve patients' adherence to phosphorus and overall nutritional guidelines.

METHODS

This cross-sectional observational study was conducted on sixty eight hemodialysis patients, 19 renal nurses and 11 nephrologists who were recruited from 3 hemodialysis units in Greece. Phosphorus nutritional knowledge of the participants was assessed by a 25-item item questionnaire (CKDKAT-N) which included 15 questions on phosphorus and 10 questions on protein, sodium, and potassium knowledge.

RESULTS

Nephrologists had higher CKDKAT-N total (19.1 ± 3.6 vs 14.1 ± 2.8 and 13.2 ± 2.8, P < 0.01) and phosphorus knowledge scores (10.6 ± 2.7 vs 7.6 ± 2.2 and 7.3 ± 2.0, P < 0.01) compared to renal nurses and patients respectively. There were no differences in total and phosphorus knowledge scores between nurses and patients. Patients and nurses answered correctly significantly less questions regarding phosphorus compared with the rest of the questions (P < 0.01) while no such difference was found in nephrologists. Serum phosphorus was positively correlated with phosphorus knowledge score (r = 0.31, P = 0.02), and negatively correlated with patient age (r = -0.34, P < 0.05). None of the patients, 11% of the nurses and 27% of the nephrologists answered correctly all three questions regarding P, K and Na dietary recommendations (P < 0.01).

CONCLUSIONS

The study confirms that hemodialysis patients have low renal nutrition knowledge while higher nutritional phosphorus knowledge does not lead to lower serum phosphorus values. Alarmingly, renal nurses have been found to have a similar level of knowledge with hemodialysis patients, something that needs to be taken into account when training the new dialysis staff. Nephrologists have superior knowledge; however they are still lacking essential nutritional knowledge that could affect patients' and nurses' overall understanding. Continuing education on nutrition of nephrologists and renal nurses could improve nutrition care of hemodialysis patients.

The state of nutrition care in outpatient hemodialysis settings in Malaysia: a nationwide survey

BACKGROUND

This study aimed to assess the situational capacity for nutrition care delivery in the outpatient hemodialysis (HD) setting in Malaysia by evaluating dietitian accessibility, nutrition practices and patients' outcomes.

METHODS

A 17-item questionnaire was developed to assess nutrition practices and administered to dialysis managers of 150 HD centers, identified through the National Renal Registry. Nutritional outcomes of 4362 patients enabled crosscutting comparisons as per dietitian accessibility and center sector.

RESULTS

Dedicated dietitian (18%) and visiting/shared dietitian (14.7%) service availability was limited, with greatest accessibility at government centers (82.4%) > non-governmental organization (NGO) centers (26.7%) > private centers (15.1%). Nutritional monitoring varied across HD centers as per albumin (100%) > normalized protein catabolic rate (32.7%) > body mass index (BMI, 30.7%) > dietary intake (6.0%). Both sector and dietitian accessibility was not associated with achieving albumin ≥40 g/L. However, NGO centers were 36% more likely (p = 0.030) to achieve pre-dialysis serum creatinine ≥884 μmol/L compared to government centers, whilst centers with dedicated dietitian service were 29% less likely (p = 0.017) to achieve pre-dialysis serum creatinine ≥884 μmol/L. In terms of BMI, private centers were 32% more likely (p = 0.022) to achieve BMI ≥ 25.0 kg/m² compared to government centers. Private centers were 62% less likely (p <  0.001) while NGO centers were 56% less likely (p <  0.001) to achieve serum phosphorus control compared to government centers. Patients from centers with a shared/visiting dietitian had 35% lower probability (p <  0.001) to achieve serum phosphorus levels below 1.78 mmol/L compared to centers without access to a dietitian.

CONCLUSIONS

There were clear discrepancies in nutritional care in Malaysian HD centers. Changes in stakeholder policy are required to ensure that dietitian service is available in Malaysian HD centers.

High Blood flow Rates with Adjustment of Needle Diameter do not Increase Hemolysis during Hemodialysis Treatment

Background

Higher blood flow in dialysis therapy is often avoided due to concerns about shear-induced blood damage despite the lack of reliable data.

Objective

This study investigated the influence of higher blood flow rates on plasma free hemoglobin (Hb) concentration after hemodialysis (HD) treatment.

Methods

Thirty-two chronic HD patients were treated once with a blood flow rate of 250 mL/min using a 17G needle, and once with a blood flow rate of 500 mL/min using a 14G needle. Arterial and venous pressure and blood pressure (BP) were recorded before and after treatment. Blood samples were taken before and after treatment for analysis of plasma free Hb, pH, HCO3, base excess, hematocrit value, urea, sodium, potassium and calcium.

Results

HD treatment at blood flow rates of 500 mL/min did not increase plasma free Hb compared to treatments at blood flow rates of 250 mL/min. Frequency of intradialytic BP drops was not different either. By adaptation of the needle size, negative arterial pressure could be kept at a similar level. Urea reduction rates were significantly higher during treatments with higher blood flow rates.

Conclusion

Higher blood flow rates can be applied without an increased hemolysis risk provided that needle sizes are adapted accordingly.

Effect of Hemodialysis on Whole Blood Viscosity

Purpose

The purpose of the present study was to examine the effect of hemodialysis procedures on the hemoconcentration status of end-stage renal disease (ESRD) patients.

Methods

We measured whole blood viscosity (WBV) of 30 ESRD patients using a scanning-capillary-tube viscometer before and after hemodialysis. The blood sample size required for WBV measurements was approximately 3 mL. Pre-dialysis specimens for viscosity measurements were obtained via the fistula needle or Perma catheter prior to initiating hemodialysis, and post-dialysis specimens were drawn from the arterial sample port of the hemodialysis line 3.5 hours after initiation of dialysis treatment.

Results

Changes in WBV were measured at high and low shear rates: 80% of patients showed an increased high shear viscosity, whereas 73% of patients demonstrated an increased low shear viscosity. The actual percentage increase in WBV observed after hemodialysis at high and low shear rate ranges varied broadly in the 30 patients.

Conclusions

The observed increase in the WBV of ESRD patients over hemodialysis procedures indicates that a segment of patients experience increased flow resistance, particularly at the microcirculatory level. In addition, for the segment of patients experiencing marked increases in WBV during hemodialysis, the vessel wall at the dialysis fistula is exposed to blood with a higher viscosity than at the beginning of the process. The higher blood viscosity at the dialysis fistula is directly related to increased kinetic force and shear stress on the vessel wall, which may be playing a role in increasing the risk of stenosis.

An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease

BACKGROUND

Dietary modification is an important component of the management of end stage kidney disease (ESKD). The diet for ESKD involves modifying energy and protein intake, and altering sodium, phosphate, potassium and fluid intake. There have been no comprehensive reviews to date on this topic. The aims of this integrative review were to (i) describe the methods used to measure dietary adherence (ii) determine the rate of dietary adherence and (iii) describe factors associated with dietary adherence in ESKD.

METHODS

The Web of Science and Scopus databases were searched using the search terms 'adherence' and 'end stage kidney disease'. Of the 787 potentially eligible papers retrieved, 60 papers of 24,743 patients were included in this review. Of these papers, 44 reported the rate of dietary adherence and 44 papers described factors associated with adherence.

RESULTS

Most of the evidence regarding dietary adherence is derived from studies of hemodialysis patients (72% of patients). The most common method of measuring dietary adherence in ESKD was subjective techniques (e.g. food diaries or adherence questionnaires). This was followed by indirect methods (e.g. serum potassium, phosphate or interdialytic weight gain). The weighted mean adherence rate to ESKD dietary recommendations was 31.5% and 68.5% for fluid recommendations. Adherence to protein, sodium, phosphate, and potassium recommendations were highly variable due to differences in measurement methods used, and were often derived from a limited evidence base. Socioeconomic status, age, social support and self-efficacy were associated with dietary adherence. However, factors such as taste, the impact of the diet on social eating occasions; and dietetic staffing also appear to play a role in dietary adherence.

CONCLUSION

Dietary adherence rates in people with ESKD are suboptimal. Further research is required on dietary adherence in patients with ESKD from different social, educational, economic and ethnic groups. This research may identify other factors which may impact upon adherence, and could be used to inform the design of future strategies to improve dietary adherence. Future research that reports not just the rate of adherence to individual components of the nutrient prescription but also the overall quality of the diet would be useful.

The Diet and Haemodialysis Dyad: Three Eras, Four Open Questions and Four Paradoxes. A Narrative Review, Towards a Personalized, Patient-Centered Approach

The history of dialysis and diet can be viewed as a series of battles waged against potential threats to patients' lives. In the early years of dialysis, potassium was identified as "the killer", and the lists patients were given of forbidden foods included most plant-derived nourishment. As soon as dialysis became more efficient and survival increased, hyperphosphatemia, was identified as the enemy, generating an even longer list of banned aliments. Conversely, the "third era" finds us combating protein-energy wasting. This review discusses four questions and four paradoxes, regarding the diet-dialysis dyad: are the "magic numbers" of nutritional requirements (calories: 30-35 kcal/kg; proteins > 1.2 g/kg) still valid? Are the guidelines based on the metabolic needs of patients on "conventional" thrice-weekly bicarbonate dialysis applicable to different dialysis schedules, including daily dialysis or haemodiafiltration? The quantity of phosphate and potassium contained in processed and preserved foods may be significantly different from those in untreated foods: what are we eating? Is malnutrition one condition or a combination of conditions? The paradoxes: obesity is associated with higher survival in dialysis, losing weight is associated with mortality, but high BMI is a contraindication for kidney transplantation; it is difficult to limit phosphate intake when a patient is on a high-protein diet, such as the ones usually prescribed on dialysis; low serum albumin is associated with low dialysis efficiency and reduced survival, but on haemodiafiltration, high efficiency is coupled with albumin losses; banning plant derived food may limit consumption of "vascular healthy" food in a vulnerable population. Tailored approaches and agreed practices are needed so that we can identify attainable goals and pursue them in our fragile haemodialysis populations.

Hemodialysis Treatment Time: As Important as it Seems?

Hemodialysis treatment time and Kt/V can both be considered to be primary measures of hemodialysis adequacy, because when either goes to zero, mortality is certain in patients without residual kidney function. Treatment time is important, but it needs to be adjusted based on surface-area-normalized Kt/V, residual kidney function, and expected ultrafiltration rate. Rescaling dose of dialysis measured as Kt/V to body surface area prevents ultrashort dialysis in small patients, women, and children with minimal residual kidney function. Most if not all of the observational studies of associations between outcome and dialysis session length are probably confounded by dose targeting bias. Once adequate Kt/V (taking into account body surface area) has been provided, adequate dialysis time probably is most relevant in terms of limiting the need for a high fluid removal rate. The latter may adversely impact survival by causing recurrent ischemia to cardiovascular and other tissues. There is little high-quality evidence at this time to support a minimum 4-hour treatment time for all patients, regardless of body size, solute removal, or residual kidney function. On the other hand, there is little evidence that prolonging weekly treatment time up to 24 hours per week is harmful. The final decision regarding treatment time is best individualized, based on patient acceptability and experience, residual kidney function, body surface-area-normalized Kt/V, and expected ultrafiltration rate.

Nonadherence with Immunosuppressive Drugs: Us Compared with European Kidney Transplant Recipients

Background

System factors increasingly are suggested as important yet understudied correlates of nonadherence.

Objective

To explore the relationship between healthcare system and prevalence of nonadherence with immunosuppressive regimen by studying variation in nonadherence between European and US kidney transplant recipients and as well as nonadherence in European countries.

Methods

We performed a secondary data analysis on data collected in 3 independent cross-sectional studies using comparable methodology including patients from the United States, the Netherlands, Belgium, and Switzerland. Nonadherence was measured using 1 item of the Siegal questionnaire. Patients were categorized as nonadherent if they reported missing a dose of immunosuppression in the last 4 weeks. Analyses were performed by multiple mixed logistic regression, with center as a random effect and clinical and demographical differences between groups as fixed effects.

Results

1563 US and 614 European patients from 3 different countries (Belgium [n=187], the Netherlands [n=85], and Switzerland [n=342]) were included. Prevalence of nonadherence in the United States and Europe was 19.3% and 13.2.%, respectively. This higher nonadherence in US patients was confirmed in a multiple logistic regression analysis (OR=1.78; 95% CI, 1.10–2.89). Nonadherence differed between Belgium (16%) and the Netherlands (14.1%) (OR=0.27; 95% CI, 0.09–0.80) and between Belgium and Switzerland (11.4%; OR=0.17; 95% CI, 0.0–0.42).

Conclusion

This is the first study showing differences in prevalence of nonadherence between European and US patients and among European patients. Further research should aim at unraveling the dynamics explaining these differences.

Scale development study: The Fluid Control in Hemodialysis Patients

AIM

The aim of this study was to develop a valid and reliable measurement instrument to identify knowledge, behaviors, and attitudes of hemodialysis (HD) patients about fluid control as these patients are inadequate in ensuring and sustaining fluid control.

METHODS

The sample of this methodological study consisted of 276 HD patients who are being treated in two public and two private hemodialysis centers. The validity of the scale was assessed through content validity, construct validity, and similar scale validity, and its reliability through item analysis, internal consistency coefficient and test-retest. For the content validity of the scale, expert views were assessed, and opinions of a Turkish language specialist were obtained.

RESULTS

According to the exploratory factor analysis, the scale had 24 items and three subdimensions, namely, knowledge, behavior, and attitude. The total variance explained was found to be 51.15%. Cronbach's alpha reliability coefficient of the Fluid Control in Hemodialysis Patients Scale (FCHPS) turned out to be 0.88 and Cronbach's alpha for its subdimensions were 0.92, 0.80, and 0.67, respectively. The correlation value between test and retest was 0.94 (P < 0.001). A moderate significant correlation (r = 0.58, P < 0.001) was found between the scale scores and the scores of the Dialysis Diet and Fluid Restrictions Non-adherence Questionnaire.

CONCLUSION

The FCHPS that was developed has good validity and reliability. This scale can be used to measure knowledge, behavior, and attitude of hemodialysis patients about fluid restriction.

Patients' adherence to aspects of haemodialysis regimens in tropical north Queensland, Australia

BACKGROUND

Patients with end-stage kidney disease often have difficulty in adhering to aspects of their haemodialysis regimens.

OBJECTIVES

This study aimed to quantify the number of patients who attended 100% of their scheduled haemodialysis sessions, and the number of patients who gained no more than one kilogram per day between dialysis sessions, over a three-month period.

DESIGN

Retrospective chart audit

PARTICIPANTS

Patients undergoing haemodialysis at an in-hospital centre in tropical Australia.

METHODS

A renal nurse audited the 72 charts pertaining to a 12-week period in 2013.

RESULTS

Patients attended 90.1% of all scheduled dialysis sessions. Forty-one patients attended all sessions, with the remaining 31 missing at least one scheduled session. One patient missed 16 scheduled sessions. The following were statistically less likely to attend all their scheduled sessions: Aboriginal and Torres Strait Islander patients; patients on a three times per week dialysis schedule; patients who had relocated from rural or regional towns and younger patients. The average daily weight gain ranged from 0.414 kg to 1.017 kg (mean = 0.885 kg). Younger patients were statistically less likely to adhere to fluid restrictions; patients without diabetes were more likely to adhere to the fluid allowances.

CONCLUSIONS AND APPLICATIONS TO PRACTICE

Renal services need to assist patients to adhere to their regimens. Initially, this service will examine strategies to maximise the likelihood of patients attending all of their dialysis sessions. Such an outcome will help to delay deterioration in the patients' health status, while minimising additional strain on the health service.

Management of mineral metabolism in hemodialysis patients: discrepancy between interventions and perceived causes of failure

BACKGROUND

Mineral and bone disorders (MBD) in patients undergoing hemodialysis (HD) are a major clinical complication. Current therapeutic strategies do not attain the expected results. The Italian audit on mineral metabolism was implemented to investigate MBD management through a "patient-oriented" approach.

METHODS

Clinical and laboratory data pertinent to MBD from 509 prevalent adult patients on chronic HD were recorded and examined (audit), after which individual strategies were elaborated to improve MBD control. Their effectiveness was evaluated 6 months after the audit (Post-6).

RESULTS

The audit disclosed poor MBD control in a high percentage of patients (56 %). Low compliance to treatment was the major determinant of failure (in 43.5 % of cases). Logistic regression showed a direct correlation between high degree of compliance and the achievement of therapeutic targets, e.g. parathyroid hormone: odds ratio (OR) 2.48, p = 0.015. In contrast, a minority of the proposed interventions (14.7 %) included strategies to improve patient compliance. At Post-6, despite a significant increase in drug prescription (p < 0.05 vs. audit), the rate of successful MBD control was unchanged.

CONCLUSIONS

Low compliance with treatment is a major, but still neglected, cause of failure in the achievement of MBD control in HD patients.

Does the extracorporeal blood flow affect survival of the arteriovenous vascular access?

Hemodiafiltration with high-convective volumes is associated with improved patient survival, whereby practical realization is contingent on high extracorporeal blood flow (Qb) and dialysis treatment time. However, Qb is restricted by vascular access (VA) quality and/or concerns that high Qb could damage the VA. Taking VA quality into consideration, one can investigate the relationship between Qb and VA survival. We analyzed data from 1039 patients treated by hemodiafiltration over a 21-month period where access blood flow (Qa) measurements were also available at baseline. VA failure was defined as a surgical intervention resulting in the generation of a new VA. Qa was included as a stratification variable within a Cox regression model. A second Cox proportional hazard model with a penalized spline was used to describe the association between Qb and VA survival. Compared with Qb in the 350-357 mL/min range, a significantly higher hazard ratio (HR) for VA failure was detected for fistula only, and then only for Qb < 312 mL/min (HR: 2.361, 95% confidence interval [CI]: 1.251-4.453), Qb = 387-397 mL/min (HR: 1.920, 95% CI: 1.007-3.660) and Qb >414 mL/min (HR: 2.207, 95% CI: 1.101-4.424). Age, gender, diabetes, VA vintage, position of the VA, and arterial pressure were not significantly associated with outcome. The form of the penalized spline confirmed higher risk for VA failure for the lowest and the highest values of Qb. Taking Qa into consideration, no association was found between VA failure and Qb up to flows as high as approximately 390 mL/min.

Nonadherence in dialysis patients: prevalence, measurement, outcome, and psychological determinants

Nonadherence to aspects of the management of End-Stage Kidney Disease (ESKD) is common. Estimates of nonadherence vary with assessment method. Whilst readily available and free from report bias, physiological proxies-frequently used as measures of adherence-are often confounded by clinical factors including residual kidney function and dialysis adequacy. Despite variation in estimates of its prevalence, it is clear that suboptimal adherence to dialysis prescriptions, medication and diet can lead to adverse clinical outcomes. Several factors can help explain nonadherence in ESKD including mood, self-efficacy, social support, illness, and treatment perceptions. Psychological interventions have been shown to improve ESKD adherence, yet achieving long-term behavior change remains challenging. Identifying individuals who struggle to adhere to aspects of the dialysis regime, and tailoring theory-led interventions to improve and support adherence is a clear clinical need requiring further empirical enquiry.

Prevalence and predictors of nonadherence to hemodialysis

BACKGROUND

The prevalence of nonadherence to dialysis (NAD) presents a wide variation, depending on the parameters used and demographic regions studied. This study aimed to assess the prevalence and predictors of NAD of patients with chronic kidney disease undergoing hemodialysis (HD).

MATERIALS AND METHODS

This was a cross-sectional study with 255 adult patients receiving HD for >3 months. Skipping a session per month, shortening a session for at least 10 min, phosphorus >7.5 mg/dl, potassium >6.0 mmol/l and interdialytic weight gain (IDWG) >5.7% of body weight were indicative of NAD. The association of sociodemographic and clinical variables with NAD was assessed using logistic regression.

RESULTS

Mean age was 50 ± 13.1 years, 62.7% were male, 85.5% were of African descent and 62% were married. The prevalence rates of NAD were: 49% of shortening sessions, 18% of hyperkalemia, 12% of hyperphosphatemia, 9% of IDWG >5.7% of dry weight and 8% of skipping HD. Independent predictors of NAD were: age ≤50 years, not being married, living alone, living in Salvador, attending dialysis without a companion, ethnic African descent, Kt/V <1.3 and residual diuresis <100 ml/day.

CONCLUSION

NAD is frequent and distinct sociodemographic and clinical variables predict different parameters.

Significance of interdialytic weight gain versus chronic volume overload: consensus opinion

Predialysis volume overload is the sum of interdialytic weight gain (IDWG) and residual postdialysis volume overload. It results mostly from failure to achieve an adequate volume status at the end of the dialysis session. Recent developments in bioimpedance spectroscopy and possibly relative plasma volume monitoring permit noninvasive volume status assessment in hemodialysis patients. A large proportion of patients have previously been shown to be chronically volume overloaded predialysis (defined as >15% above 'normal' extracellular fluid volume, equivalent to >2.5 liters on average), and to exhibit a more than twofold increased mortality risk. By contrast, the magnitude of the mortality risk associated with IDWG is much smaller and only evident with very large weight gains. Here we review the available evidence on volume overload and IDWG, and question the use of IDWG as an indicator of 'nonadherence' by describing its association with postdialysis volume depletion. We also demonstrate the relationship between IDWG, volume overload and predialysis serum sodium concentration, and comment on salt intake. Discriminating between volume overload and IDWG will likely lead to a more appropriate management of fluid withdrawal during dialysis. Consensually, the present authors agree that this discrimination should be among the primary goals for dialysis caretakers today. In consequence, we recommend objective measures of volume status beyond mere evaluations of IDWG.

Use of phosphate-binding agents is associated with a lower risk of mortality

Hyperphosphatemia has been associated with higher mortality risk in CKD 5 patients receiving dialysis. Here, we determined the association between the use of single and combined phosphate-binding agents and survival in 6797 patients of the COSMOS study: a 3-year follow-up, multicenter, open-cohort, observational prospective study carried out in 227 dialysis centers from 20 European countries. Patient phosphate-binding agent prescriptions (time-varying) and the case-mix-adjusted facility percentage of phosphate-binding agent prescriptions (instrumental variable) were used as predictors of the relative all-cause and cardiovascular mortality using Cox proportional hazard regression models. Three different multivariate models that included up to 24 variables were used for adjustments. After multivariate analysis, patients prescribed phosphate-binding agents showed a 29 and 22% lower all-cause and cardiovascular mortality risk, respectively. The survival advantage of phosphate-binding agent prescription remained statistically significant after propensity score matching analysis. A decrease of 8% in the relative risk of mortality was found for every 10% increase in the case-mix-adjusted facility prescription of phosphate-binding agents. All single and combined therapies with phosphate-binding agents, except aluminum salts, showed a beneficial association with survival. The findings made in the present association study need to be confirmed by randomized controlled trials to prove the observed beneficial effect of phosphate-binding agents on mortality.

Factors influencing adherence among Irish haemodialysis patients

OBJECTIVE

Adherence to dietary and fluid restrictions among haemodialysis patients with end stage renal failure (ESRD) is a multi-factorial concept. This study seeks to assess the predictive value of demographic and psychological variables in non-adherence.

METHODS

A multi-centre cross sectional design assessed 50 haemodialysis patients on self reported adherence, attitudes towards dietary restrictions, quality of life, depression and anxiety. Adherence to fluid and dietary restrictions was measured objectively using potassium (K), phosphorus (PO4) and inter-dialytic weight gain (IDWG) parameters.

RESULTS

62% of patients were non-adherent with at least one aspect of the treatment regime. Regression analysis revealed age as significantly associated with adherence, in particular IDWG, with younger patients displaying poorer adherence.

CONCLUSION

Younger patients may experience greater difficulty integrating complex treatment demands into their lifestyles, and non-adherence may be a consequence of the severe lifestyle limitations imposed by the haemodialysis treatment regime.

PRACTICE IMPLICATIONS

Individualised interventions may be more effective than traditional methods of adherence monitoring in reducing the non-adherent behaviour.

Effect of health contract intervention on renal dialysis patients in Korea

This study is a randomized, controlled trial to examine the effect of the health contract intervention, based on the goal attainment theory, on the self-care behavior and physiological indices of renal dialysis patients in Korea. The experimental group (n = 21) underwent health contract intervention for 4 weeks, while the control group (n = 22) received routine care. The data were collected using questionnaires and measurement of physiological indices and analyzed using the SPSS WIN 12.0 program. A P value < 0.05 was considered statistically significant. Total score of self-care behavior (P = 0.011) and individual scores for behaviors, such as diet (P = 0.017), exercise and rest (P = 0.001), and blood pressure and body weight (P = 0.006) were higher in the experimental group. Serum potassium concentration and mean weight gain between dialysis sessions were significantly low in the experimental group (P = 0.002, P = 0.017). Therefore, the health contract intervention based on the goal attainment theory proved effective in improving self-care behavior and physiological indices (K, P, mean weight gain) in renal dialysis patients in Korea.

Do hemodialysis adequacy data reflect reality?

Hemodialysis (HD) adequacy requires monitoring in line with standards and at appropriate intervals. However, the use of inappropriate or incorrectly applied techniques in the determination of HD adequacy can lead to highly unfortunate results. This study was intended to identify the path to a solution by determining how far HD adequacy in HD centers in our region reflects reality. Three hundred and thirty HD patients from eight centers were included. On the first visit, predialysis and postdialysis blood collection with the centers' own methods being used were observed and errors were recorded. Kt/V1 was calculated from pre- and postdialysis blood specimens taken by the units themselves. On the second visit, one session later, pre- and postdialysis blood samples were collected in line with guidelines by ourselves, the authors, and Kt/V2 was calculated from these samples. The eight units' total Kt/V2 value was significantly lower compared with Kt/V1 (<0.0001). The level of patients in all centers with Kt/V1 <1.2 was 13.5%, and that of patients with Kt/V2 <1.2 was 22.1%. No center, apart from one unit, managed to complete the collection of blood specimens as recommended by the guidelines. With one exception, blood collection for HD adequacy was not performed using proper technique in any center. This simple but easily overlooked situation, HD being regarded as adequate though in fact it is not, may lead to patients not being treated effectively and accurately and to a rise in mortality and morbidity in the long term.

Managing treatment for end-stage renal disease--a qualitative study exploring cultural perspectives on facilitators and barriers to treatment adherence

Although adherence to hemodialysis (HD) regimes is important to maximise good clinical outcomes, it remains suboptimal and not well understood, particularly for those in non-Western settings and patients from Asian cultures. This qualitative study sought to explore cultural perspectives on facilitators and barriers to treatment adherence in HD patients. A descriptive exploratory design was used for the study, incorporating individual semi-structured interviews (n = 17) and three focus groups (n = 20). Each interview/focus group was audio-taped and transcribed verbatim, and coding was conducted by two coders using an iterative process. Study participants identified personal and social/contextual factors as major barriers or facilitators of treatment adherence. Barriers include time consumption, forgetfulness, concerns about safety, poor knowledge/understanding, poor communication and lack of control/social pressure. Participants also identified facilitators, both internal (self-initiated) and external (initiated by family, health care professional and peers) to ensure treatment adherence. These included support from family members and social obligation towards others, risk perception, establishment of routines and peer support. Internal and external factors can hinder or facilitate adherence to diet, fluid and medications in the context of dialysis. Several of these barriers/facilitators can be effectively addressed in the context of interventions and psycho-educational programmes.

Epidemiology of end-stage renal disease and hemodialysis treatment in Serbia at the turn of the millennium

The study presents the epidemiological features of patients treated with renal replacement therapy (RRT) in Serbia from 1997 to 2009 and compares the results of hemodialysis treatment in 1999 and 2009. Epidemiological data were obtained from the National Registry of RRT patients and data on hemodialysis treatment from special surveys conducted in 1999 and 2009. Within the period 1997-2009 the incidence of patients on RRT increased from 108 to 179 per million population (pmp), prevalence rose from 435 to 699 pmp, while mortality rate fell from 20.7% to 16.7%. The frequency of patients with glomerulonephritis decreased, while that of patients with diabetes and hypertensive nephropathy increased. In late 2009 there were 5208 patients receiving RRT in Serbia. Within the examined period new hemodialysis and reverse osmosis equipment were purchased, high-flux dialyzers with synthetic membranes were increasingly used and the number of patients receiving hemodiafiltration increased to 17.6%. Kt/V greater than 1.2 was recorded in 16% of the patients in 1999 but 52% in 2009. Options for correction of anemia and mineral disorders have also improved. The percentage of patients with HbsAg (13.8% vs. 4.8%) as well as anti-hepatitis C virus antibodies positive patients (23.2% vs. 12.7%) was significantly lower in 2009 than in 1999. Both the incidence and prevalence of RRT patients in Serbia are rising continuously, while the mortality rate is falling. More favorable conditions for dialysis treatment have brought about significant improvement in the results over the last 10 years.

Changes in Whole Blood Viscosity at Low Shear Rates Correlate with Intravascular Volume Changes during Hemodialysis

Background:

Elevated blood viscosity has been shown to be independently correlated with cardiovascular risk factors and associated with increased risk of major cardiovascular events, including death and acute myocardial infarction. The aim of the present study was to investigate changes in whole blood viscosity (WBV) at shear rates of 1, 5, and 300 s-1 before and after hemodialysis in patients with end-stage renal disease (ESRD). We also examined the relationship between the changes of WBV and intravascular blood volume.

Methods:

43 patients with ESRD receiving maintenance hemodialysis were enrolled. WBV was measured using a scanning capillary tube viscometer pre- and post-dialysis to quantify dialytic viscosity surges. Body weight, blood pressure, and hematocrit were also measured before and after hemodialysis, as was the fluid removed during the session.

Results:

Hemodialysis had a 3 times greater impact on the low-shear WBV at a shear rate of 1 s-1 (i.e., 44.1% change) than on the high-shear WBV at a shear rate of 300 s-1 (i.e., 15.9% change). Changes in the low-shear WBV obtained at shear rates of 1 and 5 s-1 during hemodialysis were significantly correlated with changes in hematocrit. The intravascular blood volume reduction during hemodialysis was positively correlated with the changes in both high-shear and low-shear WBVs.

Conclusions:

These results suggest that the WBV parameter may hold additional information beyond hemoconcentration. Further research is needed to evaluate the relationship between low-shear WBV surges and increased morbidity in the patient population with ESRD.

[Interest of a specific programme in patient education for dialysis in out-center patients]

The development of therapeutic patient education for dialysis patients is recent and concerns mainly out-center patients. To our knowledge, only two papers centred on therapeutic education with out-center patients have been published. The particularities of this dialysis modality (unit close to the home, more autonomy, a nurse for six patients, organisation of unit, better quality of life and psychological status) highlight the interest to develop specific educational programs for patients treated in out-center sitting. The example of a program in Aquitaine (France) composed of mainly collective sessions (representations of the disease, dietetic recommendations, hygiene and protection of the vascular access, drugs compliance…) allows to propose several practical implications to initiate the development of specific programs in therapeutic education for out-center dialysis: educative sessions during the sessions of dialysis, group patients, multidisciplinary team, evaluation of the program from a medical and psychosocial point of view…

International differences in hemodialysis delivery and their influence on outcomes

There are many variations in the delivery of hemodialysis. These variations include components of conventional dialysis, such as membrane type, dialysis dose, and session duration. In addition, alternative approaches to dialysis, such as hemodiafiltration, nocturnal hemodialysis, and short daily hemodialysis, also may be considered. For some of these practice variations, data exist to support one approach over another (eg, fistulas rather than grafts and catheters), but for many, no such data exist. Very few practice variations have been examined in randomized trials, and we are reliant predominantly on observational data. This review examines some practice variations in hemodialysis delivery, attempting to highlight which of these may be appropriate to consider when optimizing dialysis delivery in the clinic.

Family relations, mental health and adherence to nutritional guidelines in patients facing dialysis initiation

This study investigated the effect of family relations on patients' adjustment to dialysis. The two main aims were to develop a family typology, and to explore the influence of family profile on the patient's anxiety, depression and adherence to nutritional guidelines. The sample consisted of 120 patients (mean age 63 years; 67.5% of men). They completed several measures 1, 6 and 12 months after dialysis initiation. The scales used were the Family Relationship Index and the Hospital Anxiety and Depression Scale. Perceived adherence to nutritional guidelines was assessed using two visual analogical scales. Results showed that family relations remained stable over time. Cluster analysis yielded three family profiles, which were named conflict, communicative and supportive families. Patients belonging to conflict families perceived themselves as less adhering to nutritional guidelines. For these patients, anxiety and depressive moods increased significantly over time, whereas mental health remained stable over time for communicative and supportive families. This research underlines that family relations are essential in global consideration of the care of patients treated by dialysis. Conflict families seem especially at risk. They should be identified early to help them adapt to this stressful treatment.