Symptoms and their recognition in adult haemodialysis patients: Interactions with quality of life

Estimating a Minimal Important Difference for the EQ-5D-5L Utility Index in Dialysis Patients

OBJECTIVES

The EQ-5D-5L is a commonly used health-related quality of life instrument for evaluating interventions in patients receiving dialysis; however, the minimal important difference (MID) that constitutes a meaningful treatment effect for this population has not been established. This study aims to estimate the MID for the EQ-5D-5L utility index in dialysis patients.

METHODS

6-monthly EQ-5D-5L measurements were collected from adult dialysis patients between April 2017 and November 2020 at a renal network in Sydney, Australia. EQ-VAS and Integrated Palliative care Outcome Scale Renal symptom burden scores were collected simultaneously and used as anchors. MID estimates for the EQ-5D-5L utility index were derived using anchor-based and distribution-based methods.

RESULTS

A total of 352 patients with ≥1 EQ-5D-5L observation were included, constituting 1127 observations. Mean EQ-5D-5L utility index at baseline was 0.719 (SD ± 0.267), and mean EQ-5D-5L utility decreased over time by -0.017 per year (95% CI -0.029 to -0.006, P = .004). Using cross-sectional anchor-based methods, MID estimates ranged from 0.073 to 0.107. Using longitudinal anchor-based methods, MID for improvement and deterioration ranged from 0.046 to 0.079 and -0.111 to -0.048, respectively. Using receiver operating characteristic curves, MID for improvement and deterioration ranged from 0.037 to 0.122 and -0.074 to -0.063, respectively. MID estimates from distribution-based methods were consistent with anchor-based estimates.

CONCLUSIONS

Anchor-based and distribution-based approaches provided EQ-5D-5L utility index MID estimates ranging from 0.034 to 0.134. These estimates can inform the target difference or "effect size" for clinical trial design among dialysis populations.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Delivering Person-Centered Peritoneal Dialysis

Peritoneal dialysis (PD) enables people to have a home-based therapy, permitting greater autonomy for individuals along with enhanced treatment satisfaction compared with in-center dialysis care. The burden of treatment on PD, however, remains considerable and underpins the need for person-centered care. This reflects the need to address the patient as a person with needs and preferences beyond just the medical perspective. Shared decision making is central to the recent International Society for Peritoneal Dialysis recommendations for prescribing PD, balancing the potential benefits of PD on patient well-being with the burden associated with treatment. This review considers the role of high-quality goal-directed prescribing, incremental dialysis, and remote patient monitoring in reducing the burden of dialysis, including an approach to implementing incremental PD. Although patient-related outcomes are important in assessing the response to treatment and, particularly life participation, the corollary of dialysis burden, there are no clear routes to the clinical implementation of patient-related outcome measures. Delivering person-centered care is dependent on treating people both as individuals and as equal partners in their care.

Live music during haemodialysis: A multiple methods randomised controlled pilot study

BACKGROUND

Fatigue is an immense problem among patients undergoing haemodialysis and is associated with anxiety and depression. Live music used in different hospital settings has shown promising effects, but the feasibility and potential effectiveness of live music during haemodialysis are unknown.

OBJECTIVES

To evaluate the feasibility, the participants' musical experience and potential effectiveness of live music on patients' levels of fatigue, relaxation, anxiety, depression, treatment satisfaction and work engagement among nurses.

DESIGN

A pilot randomised controlled trial evaluated with a multiple methods design.

PARTICIPANTS

Two clusters of 12 patients were each randomised to receive either 30 min of live music once a week during haemodialysis or usual care over a period of 6 weeks.

MEASUREMENTS

The primary outcome was patients' immediate fatigue. Other outcomes were patients' long-term and post-dialysis fatigue, relaxation, anxiety, depression, treatment satisfaction and work engagement among nurses. Observations and semi-structured interviews with patients, nurses and musicians were conducted to gain an in-depth understanding of the musical experience as well as feasibility.

RESULTS

The study was feasible and detected significant differences on immediate fatigue (p < 0.001) and anxiety (p < 0.012) in the intervention group compared to controls. Among 17 nurses, a significant difference was found in Dedication (p < 0.024). Furthermore, live music gave patients an uplifting experience, bringing joy and relaxation and the nurses experienced a sense of quietness in a stressful day.

CONCLUSIONS

Providing live music performed by professional musicians in a haemodialysis setting is feasible and showed a significant effect on immediate fatigue and anxiety compared to controls.

Health-related quality of life and symptom burden in patients on haemodialysis

BACKGROUND

Patients on haemodialysis (HD) generally experience poor health-related quality of life (HRQoL) and a broad range of physical and mental symptoms, but it is unknown whether this differs between younger and older patients. We aimed to describe the trajectories of HRQoL and symptom burden of patients <70 and ≥70 years old and to assess the impact of symptom burden on HRQoL.

METHODS

In incident Dutch HD patients, HRQoL and symptoms were measured with the 12-item Short Form Health Survey and Dialysis Symptom Index. We used linear mixed models for examining the trajectories of HRQoL and symptom burden during the first year of dialysis and linear regression for the impact of symptom burden on HRQoL.

RESULTS

In 774 patients, the trajectories of physical HRQoL, mental HRQoL and symptom burden were stable during the first year of dialysis. Compared with patients <70 years of age, patients ≥70 years reported similar physical HRQoL {mean difference -0.61 [95% confidence interval (CI) -1.86-0.63]}, better mental HRQoL [1.77 (95% CI 0.54-3.01)] and lower symptom burden [-2.38 (95% CI -5.08-0.32)]. With increasing symptom burden, physical HRQoL declined more in older than in younger patients (β = -0.287 versus -0.189, respectively; P-value for interaction = .007). For mental HRQoL, this decrease was similar in both age groups (β = -0.295 versus -0.288, P = .847).

CONCLUSION

Older HD patients generally experience a better mental HRQoL and a (non-statistically significant) lower symptom burden compared with younger patients. Their physical HRQoL declines more rapidly with increasing symptom burden.

Feasibility of Symptom monitoring WIth Feedback Trial (SWIFT) for adults on hemodialysis: a registry-based cluster randomized pilot trial

BACKGROUND

Patients with kidney failure on hemodialysis (HD) experience considerable symptom burden and poor health-related quality of life (HRQoL). There is limited use of patient reported outcome measures (PROMs) in facility HD units to direct immediate care, with response rates in other studies between 36 to 70%. The aim of this pilot study was to evaluate feasibility of electronic PROMs (e-PROMs) in HD participants, with feedback 3-monthly to the participants' treating team, for severe or worsening symptoms as identified by the Integrated Palliative Outcome Scale (IPOS-Renal), with linkage to the Australian and New Zealand Dialysis and Transplant (ANZDATA) registry, compared with usual care.

METHODS

This is a registry-based cluster-randomized controlled pilot trial involving all adults receiving HD in 4 satellite units in Australia over a 6-month period. HD units were cluster randomized 1:1 to the control (HRQoL data collection only) or intervention arm (symptom monitoring with feedback to treating team every 3 months). Feasibility was assessed by participant response rate (percentage of eligible HD participants, including new incident participants, who completed the questionnaire at each time point); retention rate (percentage of participants who completed the baseline questionnaire and all subsequent measures); and completion time. HRQoL and symptom burden scores are described.

RESULTS

There were 226 unique participants who completed the e-PROMs (mean age 62 years, 69% males, 78% White-European, median dialysis vintage 1.62 years). At 6 months, response rate and retention rate for the intervention arm were 54% and 68%, respectively, and 89% and 97% in the control arm. Median time to complete IPOS-Renal was 6.6 min (5.3, 10.1) at 3 months, and when combined with the outcome measure (EQ-5D-5L), the median time was 9.4 min (6.9, 13.6) at 6 months.

CONCLUSIONS

Electronic symptom monitoring among HD participants with feedback to clinicians is feasible. Variations in response and retention rates could be potentially explained by the lengthier questionnaire, and higher frequency of data collection time points for participants in the intervention arm. A definitive national RCT is underway.

TRIAL REGISTRATION

ACTRN12618001976279 (07/12/2018).

Facing the challenges of PROM implementation in Dutch dialysis care: Patients' and professionals' perspectives

BACKGROUND

Patient Reported Outcome Measures (PROMs) are increasingly used in routine clinical practice to facilitate patients in sharing and discussing health-related topics with their clinician. This study focuses on the implementation experiences of healthcare professionals and patients during the early implementation phase of the newly developed Dutch set of dialysis PROMs and aims to understand the process of early implementation of PROMs from the users' perspectives.

METHODS

This is a qualitative study among healthcare professionals (physicians and nursing staff: n = 13) and patients (n = 14) of which 12 were receiving haemodialysis and 2 peritoneal dialysis. Semi-structured interviews were used to understand the barriers and facilitators that both professionals and patients encounter when starting to implement PROMs.

RESULTS

The early PROM implementation process is influenced by a variety of factors that we divided into barriers and facilitators. We identified four barriers: patient´s indifference to PROMs, scepticism on the benefits of aggregated PROM data, the limited treatment options open to doctors and organizational issues such as mergers, organizational problems and renovations. We also describe four facilitators: professional involvement and patient support, a growing understanding of the use of PROMs during the implementation, quick gains from using PROMs such as receiving instant feedback and a clear ambition on patient care such as a shared view on patient involvement and management support.

CONCLUSIONS

In this qualitative study carried out during the early implementation phase of the Dutch dialysis PROM set, we found that patients did not yet consider the PROM set to be a useful additional tool to share information with their doctor. This was despite the professionals' primary reason for using PROMs being to improve patient-doctor communication. Furthermore, the perceived lack of intervention options was frustrating for some of the professionals. We found that nurses could be important enablers of further implementation because of their intensive relationship with dialysis patients.

The relationship between the perception of chronic disease care and health-related quality of life in adults with chronic kidney disease

OBJECTIVES

In this study, it was aimed to determine the chronic disease care assessments and health-related quality of life (HRQoL) levels in adults with chronic kidney disease (CKD) undergoing hemodialysis and to reveal the relationship between chronic disease care assessment and HRQoL.

METHODS

A single-center cross-sectional design has been used. Data were collected from 105 adults with CKD, who undergoing hemodialysis. Patient Evaluation Chronic Illness Care (PACIC) scale and Kidney Disease Quality of Life Short Form-36 (KDQOL-36) were used to obtain data.

RESULTS

The mean scale scores of PACIC were low (2.66 ± 0.891). Although participants achieved high HRQoL scores on the symptoms subdimension of the KDQoL-36 scale, they got low scores on the subdimensions of mental health, physical health, and burden of disease. Participants' HRQoL is affected significantly by gender, age, educational level, working status, income, and presence of comorbidity (especially diabetes), diagnosis time of CKD, and hemodialysis time at the hospital (p < 0.05). A positive and statistically significant relationship was found between PACIC and subdimensions of KDQoL-36 (p < 0.05).

DISCUSSION

The results can be a guide for improving the quality of chronic disease care in healthcare institutions. To improve this, patients' evaluations on this issue should be taken into account.

Discussing results of patient-reported outcome measures (PROMs) between patients and healthcare professionals in routine dialysis care: a qualitative study

OBJECTIVES

Patient-reported outcome measures (PROMs) provide insight into patients' experienced health and needs, and can improve patient-professional communication. However, little is known about how to discuss PROM results. This study aimed to provide in-depth knowledge of patients' and healthcare professionals' experiences with and perspectives on discussing PROM results as part of routine dialysis care.

DESIGN

A qualitative study was performed using an interpretive description approach. Individual semistructured interviews were conducted with 22 patients and healthcare professionals. Interviews focused on general and specific situations (eg, addressing sensitive topics or when no medical treatment is available). Interviews were transcribed verbatim and analysed inductively using thematic analysis.

SETTING

Participants were purposively sampled from eight dialysis centres across the Netherlands.

PARTICIPANTS

Interviews were conducted with 10 patients receiving dialysis treatment and 12 healthcare professionals (nephrologists and nurses).

RESULTS

Patients and healthcare professionals provided practical guidance for optimal discussion about PROM results. First, patients and healthcare professionals emphasised that PROM results should always be discussed and indicated how to create a suitable setting, adequately prepare, deal with time constraints and use PROMs as a tool for personalised holistic consultations. Second, patients should actively participate and healthcare professionals should take a guiding role. A trusting patient-professional relationship was considered a prerequisite and patient-professional interaction was described as a collaboration in which both contribute their knowledge, experiences and ideas. Third, follow-up after discussing PROM results was considered important, including evaluations and actions (eg, symptom management) structurally embedded into the multidisciplinary treatment process. These general themes also applied to the specific situations, for example: results should also be discussed when no medical treatment is available. Though, healthcare professionals were expected to take more initiative and a leading role when discussing sensitive topics.

CONCLUSIONS

This study provides insight into how to organise and conduct conversations about PROM results and lays the foundation for training healthcare professionals to optimally discuss PROM results in routine nephrology care. Further research is needed to provide guidance on follow-up actions in response to specific PROM results.

Translation, cultural adaptation, and validation of the Integrated Palliative Outcome Scale-renal (IPOS-r) to Czech

BACKGROUND

Patients with advanced kidney disease suffer from burdensome symptoms, which should be assessed by valid and reliable patient-reported outcome measures. This study aimed to provide a translation, cultural adaptation, and validation of the Czech version of the IPOS-r.

METHODS

The IPOS-r was translated to Czech and culturally adapted using cognitive interviews. During the validation phase, patients and staff in dialysis centres and outpatient renal clinics completed the IPOS-r. Internal consistency was tested with Cronbach's alpha, its reliability via intraclass correlation coefficient for total IPOS-r score, and weighted Kappa (for test-retest and interrater reliability of individual items). Convergent validity was tested with Spearman correlation to Kidney Disease Quality of Life Survey-Short Form 1.2 (KDQOL-SF 1.2). We assessed sensitivity to change using a distribution-based approach.

RESULTS

Two sets of translators independently performed forward and backward translations of the IPOS-r. Ten patients and ten health care professionals participated in cognitive pre-testing. The sample size for validation included 88 patients (mean age 66 ± SD13.8; 58% men) who were treated with haemodialysis (70.5%), home haemodialysis (5.5%), peritoneal dialysis (3%), and conservative management (21%). Cronbach's alpha was 0.72, and the intraclass correlation was 0.84 for test-retest reliability and 0.73 for interrater reliability. The IPOS-r correlated with KDQOL-SF 1.2 had a rho between 0.4-0.8 for most of the IPOS-r items, showing good convergent validity. The IPOS-r measure is feasible and takes 9 minutes to complete. Patients who reported a change in health status after 1 month demonstrated a total IPOS-r score change of eight points in both positive and negative directions.

CONCLUSIONS

The process of translation and cultural adaptation of the IPOS-r was successful, and the Czech IPOS-r measure is a valid and reliable tool. The Czech IPOS-r can be used to assess symptoms in patients with advanced chronic kidney disease.

TRIAL REGISTRATION

GAUK [82121].

Validity and reliability of Patient-Reported Outcomes Measurement Information System (PROMIS®) using Computerized Adaptive Testing (CAT) in patients with advanced chronic kidney disease

BACKGROUND

The Patient-Reported Outcomes Measurement Information System (PROMIS®) has been recommended for computerized adaptive testing (CAT) of health-related quality of life (HRQOL). This study compared the content, validity and reliability of seven PROMIS CATs to the 12-item Short-Form Health Survey (SF-12) in patients with advanced chronic kidney disease (CKD).

METHODS

Adult CKD patients with an eGFR < 30 ml/min.1.73m2 not receiving dialysis treatment completed seven PROMIS CATs (assessing physical function, pain interference, fatigue, sleep disturbance, anxiety, depression, and ability to participate in social roles and activities), the SF-12 and, additionally, the PROMIS Pain Intensity single item and Dialysis Symptom Index (DSI) at inclusion and 2-weeks. A content comparison was performed between PROMIS CATs and SF-12. Construct validity of PROMIS CATs was assessed using Pearson's correlations. Test-retest reliability of all patient-reported outcome measures (PROMs) was assessed by calculating the intra-class correlation coefficient (ICC) and minimal detectable change (MDC).

RESULTS

In total, 207 patients participated in the study. A median of 45 items (10 minutes) was completed for PROMIS CATs. All PROMIS CATs showed evidence for sufficient construct validity. PROMIS CATs, most SF-12 domains and summary scores, and DSI showed sufficient test-retest reliability (ICC ≥ 0.70). PROMIS CATs had a lower MDC compared to the SF-12 (5.7-7.4 compared to 11.2-21.7 across domains, respectively).

CONCLUSION

PROMIS CATs showed sufficient construct validity and test-retest reliability in patients with advanced CKD. PROMIS CATs required more items but showed better reliability than the SF-12. Future research is needed to investigate the feasibility of PROMIS CATs for routine nephrology care.

Symptom clusters in chronic kidney disease and their association with people's ability to perform usual activities

Background

People living with a long-term condition, such as chronic kidney disease (CKD), often suffer from multiple symptoms simultaneously, making symptom management challenging. This study aimed to identify symptom clusters in adults with CKD across treatment groups and investigate their association with people’s ability to perform their usual activities.

Methods

We conducted a secondary analysis of both cross-sectional and longitudinal data collected as part of a national service improvement programme in 14 kidney centres in England, UK. This data included symptom severity (17 items, POS-S Renal) and the extent to which people had problems performing their usual activities (single item, EQ-5D-5L). We categorised data by treatment group: haemodialysis (n = 1,462), transplantation (n = 866), peritoneal dialysis (n = 127), or CKD without kidney replacement therapy (CKD non-KRT; n = 684). We used principal component analysis to identify symptom clusters per treatment group, and proportional odds models to assess the association between clusters and usual activities.

Results

Overall, clusters related to: lack of energy and mobility; gastrointestinal; skin; and mental health. Across groups, the ‘lack of energy and mobility’ clusters were associated with having problems with usual activities, with odds ratios (OR) ranging between 1.24 (95% confidence interval [CI], 1.21–1.57) for haemodialysis and 1.56 for peritoneal dialysis (95% CI, 1.28–1.90). This association was confirmed longitudinally in haemodialysis (n = 399) and transplant (n = 249) subgroups.

Implications

Our findings suggest that healthcare professionals should consider routinely assessing symptoms in the ‘lack of energy & mobility’ cluster in all people with CKD, regardless of whether they volunteer this information; not addressing these symptoms is likely to be related to them having problems with performing usual activities. Future studies should explore why symptoms within clusters commonly co-occur and how they interrelate. This will inform the development of cluster-level symptom management interventions with enhanced potential to improve outcomes for people with CKD.

Itching in dialysis patients: impact on health-related quality of life and interactions with sleep problems and psychological symptoms – results from the RENINE/PROMs registry

Background

Itching (pruritus) is common in dialysis patients, but little is known about its impact on health-related quality of life (HRQOL), sleep problems and psychological symptoms. This study investigates the impact of itching in dialysis patients by looking into the persistence of itching, the effect of itching on the course of HRQOL and the combined effect of itching with sleep problems and with psychological symptoms on HRQOL.

Methods

Data were obtained from the RENINE/PROMs registry and included 2978 dialysis patients who completed patient-reported outcome measures between 2018 and 2020. Itching, sleep problems and psychological symptoms were assessed with the Dialysis Symptom Index (DSI) and HRQOL with the 12-item Short Form Health Survey. Effects of itching on HRQOL and interactions with sleep problems and psychological symptoms were investigated cross-sectionally and longitudinally using linear regression and linear mixed models.

Results

Half of the patients experienced itching and in 70% of them, itching was persistent. Itching was associated with a lower physical and mental HRQOL {−3.35 [95% confidence interval (CI) −4.12 to −2.59) and −3.79 [95% CI −4.56 to −3.03]}. HRQOL remained stable during 2 years and trajectories did not differ between patients with or without itching. Sleep problems (70% versus 52%) and psychological symptoms (36% versus 19%) were more common in patients with itching. These symptoms had an additional negative effect on HRQOL but did not interact with itching.

Conclusions

The persistence of itching, its impact on HRQOL over time and the additional effect on HRQOL of sleep problems and psychological symptoms emphasize the need for recognition and effective treatment of itching to reduce symptom burden and improve HRQOL.

Alterations in symptoms and health-related quality of life as kidney function deteriorates: A cross-sectional study

AIMS AND OBJECTIVES

To compare symptoms and health-related quality of life and to examine the relationship between these as kidney function deteriorates.

BACKGROUND

Chronic kidney disease is a global health problem, and while knowledge of symptom burden and health-related quality of life is understood in kidney failure (previously end-stage kidney disease), there is limited understanding about symptoms and health-related quality of life across the chronic kidney disease trajectory.

DESIGN

Cross-sectional design reported using the STROBE guidelines.

METHODS

Eight hundred eighty-six adults with varying levels of kidney function (chronic kidney disease grades 3b-5 including those receiving dialysis) completed the renal version of the Integrated Palliative care Outcome Scale and the Quality of Life Short Form-36 version 2. Socio-demographic and renal characteristics were also collected. Data were analysed using descriptive and inferential statistics.

RESULTS

Participants had a mean age of 57 years and were mostly male. Regardless of chronic kidney disease grade, pain, poor mobility, weakness, anxiety and depression were the most prevalent and severe symptoms reported. Health-related quality of life was significantly associated with physical and psychological symptom scores. As kidney function deteriorated, both physical and mental health-related quality of life decreased, and prevalence and severity of symptoms increased.

CONCLUSIONS

There is substantial symptom burden irrespective of chronic kidney disease grade, which overwhelmingly affects health-related quality of life. Early identification by nurses would enable proactive management plans to be implemented.

RELEVANCE TO CLINICAL PRACTICE

Nurses, whether in specialist renal services or in primary healthcare, are ideally placed to regularly assess symptoms and health-related quality of life in those with chronic kidney disease. Timely assessment could assist in the targeting of earlier interventions designed to reduce symptom burden and to increase health-related quality of life.

Validity and reliability of the English and translated Chinese versions of the Integrated Palliative care Outcome Scale (IPOS) in Singapore

CONTEXT

Measurement of patient-centred outcomes enables clinicians to focus on patient and family priorities and enables quality of palliative care to be assessed.

OBJECTIVES

This study aimed to evaluate the validity and reliability of the English and translated Chinese versions of the Integrated Palliative care Outcome Scale (IPOS) among advanced cancer patients in Singapore.

METHODS

IPOS was forward and backward translated from English into Chinese. Structural validity was assessed by confirmatory factor analysis; known-group validity by comparing inpatients and community patients; construct validity by correlating IPOS with Edmonton Symptom Assessment System-revised (ESAS-r) and Functional Assessment of Cancer Therapy-General (FACT-G); internal consistency by Cronbach's alpha; inter-rater reliability between patient and staff responses; test-retest reliability of patient responses between two timepoints.

RESULTS

One hundred eleven English-responding and 109 Chinese-responding patients participated. The three-factor structure (Physical Symptoms, Emotional Symptoms and Communication and Practical Issues) was confirmed with Comparative Fit Index and Tucker-Lewis-Index > 0.9 and Root Mean Square Error of Approximation < 0.08. Inpatients scored higher than outpatients as hypothesised. Construct validity (Pearson's correlation coefficient, r ≥ |0.608|) was shown between the related subscales of IPOS and FACT-G and ESAS-r. Internal consistency was confirmed for total and subscale scores (Cronbach's alpha≥0.84), except for the Communication and Practical Issues subscale (Cronbach's alpha = 0.29-0.65). Inter-rater reliability (Intra-class correlation coefficient [ICC] ≤ 0.43) between patient and staff responses was insufficient. Test-retest reliability was confirmed with Intra-class correlation coefficient ICC = 0.80 (English) and 0.88 (Chinese) for IPOS Total.

CONCLUSION

IPOS in English and Chinese showed good validity, good internal consistency, and good test-retest reliability, except for the Communication and Practical Issues subscale. There was poor inter-rater reliability between patients and staff.

The Prevalence and Severity of Chronic Pain in Patients With Chronic Kidney Disease: A Systematic Review and Meta-Analysis

Background:

Chronic pain is a common and distressing symptom reported by patients with chronic kidney disease (CKD). Clinical practice and research in this area do not appear to be advancing sufficiently to address the issue of chronic pain management in patients with CKD.

Objectives:

To determine the prevalence and severity of chronic pain in patients with CKD.

Design:

Systematic review and meta-analysis.

Setting:

Interventional and observational studies presenting data from 2000 or later. Exclusion criteria included acute kidney injury or studies that limited the study population to a specific cause, symptom, and/or comorbidity.

Patients:

Adults with glomerular filtration rate (GFR) category 3 to 5 CKD including dialysis patients and those managed conservatively without dialysis.

Measurements:

Data extracted included title, first author, design, country, year of data collection, publication year, mean age, stage of CKD, prevalence of pain, and severity of pain.

Methods:

Databases searched included MEDLINE, CINAHL, EMBASE, and Cochrane Library, last searched on February 3, 2020. Two reviewers independently screened all titles and abstracts, assessed potentially relevant articles, and extracted data. We estimated pooled prevalence of overall chronic pain, musculoskeletal pain, bone/joint pain, muscle pain/soreness, and neuropathic pain and the I² statistic was computed to measure heterogeneity. Random effects models were used to account for variations in study design and sample populations and a double arcsine transformation was used in the model calculations to account for potential overweighting of studies reporting either very high or very low prevalence measurements. Pain severity scores were calibrated to a score out of 10, to compare across studies. Weighted mean severity scores and 95% confidence intervals were reported.

Results:

Sixty-eight studies representing 16 558 patients from 26 countries were included. The mean prevalence of chronic pain in hemodialysis patients was 60.5%, and the mean prevalence of moderate or severe pain was 43.6%. Although limited, pain prevalence data for peritoneal dialysis patients (35.9%), those managed conservatively without dialysis (59.8%), those following withdrawal of dialysis (39.2%), and patients with earlier GFR category of CKD (61.2%) suggest similarly high prevalence rates.

Limitations:

Studies lacked a consistent approach to defining the chronicity and nature of pain. There was also variability in the measures used to determine pain severity, limiting the ability to compare findings across populations. Furthermore, most studies reported mean severity scores for the entire cohort, rather than reporting the prevalence (numerator and denominator) for each of the pain severity categories (mild, moderate, and severe). Mean severity scores for a population do not allow for “responder analyses” nor allow for an understanding of clinically relevant pain.

Conclusions:

Chronic pain is common and often severe across diverse CKD populations providing a strong imperative to establish chronic pain management as a clinical and research priority. Future research needs to move toward a better understanding of the determinants of chronic pain and to evaluating the effectiveness of pain management strategies with particular attention to the patient outcomes such as overall symptom burden, physical function, and quality of life. The current variability in the outcome measures used to assess pain limits the ability to pool data or make comparisons among studies, which will hinder future evaluations of the efficacy and effectiveness of treatments. Recommendations for measuring and reporting pain in future CKD studies are provided.

Trial registration:

PROSPERO Registration number CRD42020166965

Funnel plots of patient-reported outcomes to evaluate health-care quality: Basic principles, pitfalls and considerations

A funnel plot is a graphical method to evaluate health-care quality by comparing hospital performances on certain outcomes. So far, in nephrology, this method has been applied to clinical outcomes like mortality and complications. However, patient-reported outcomes (PROs; eg, health-related quality of life [HRQOL]) are becoming increasingly important and should be incorporated into this quality assessment. Using funnel plots has several advantages, including clearly visualized precision, detection of volume-effects, discouragement of ranking hospitals and easy interpretation of results. However, without sufficient knowledge of underlying methods, it is easy to stumble into pitfalls, such as overinterpretation of standardized scores, incorrect direct comparisons of hospitals and assuming a hospital to be in-control (ie, to perform as expected) based on underpowered comparisons. Furthermore, application of funnel plots to PROs is accompanied by additional challenges related to the multidimensional nature of PROs and difficulties with measuring PROs. Before using funnel plots for PROs, high and consistent response rates, adequate case mix correction and high-quality PRO measures are required. In this article, we aim to provide insight into the use and interpretation of funnel plots by presenting an overview of the basic principles, pitfalls and considerations when applied to PROs, using examples from Dutch routine dialysis care.

Impact of Renal Supportive Care on Symptom Burden in Dialysis Patients: A Prospective Observational Cohort Study

CONTEXT

Symptom burden is a strong predictor of reduced health-related quality of life and survival in patients with end-stage kidney disease. Renal supportive care (RSC) is a comprehensive approach shown to benefit symptoms in nondialysis conservatively managed patients, although its role in dialysis patients has not been reported.

OBJECTIVES

This study aimed to investigate the impacts of RSC intervention on symptoms in dialysis patients.

METHODS

Dialysis patients who were referred to an RSC clinic for symptom control between April 2010 and December 2017 were followed prospectively. Symptoms were scored using the Integrated Palliative care Outcomes Scale-Renal Inventory. Change in symptoms was analyzed at three visits and at final RSC visit within the study period. Correlation and linear regression were used to assess for effect modifiers.

RESULTS

A total of 127 dialysis patients attended the RSC clinic for symptom management. Median age was 74 years, 62% males, median dialysis vintage was 2.2 years, and median-modified Charlson Comorbidity Index was 7. Mean combined physical and emotional symptom score at baseline was 17.5 (SD 9.6), the most overwhelming/severe symptoms being difficulty sleeping (35%), pain (31%), lack of energy (31%), poor mobility (24%), and itch (22%). Eighty patients had follow-up to at least three RSC visits (median 3.1 months). There was significant improvement in combined physical and emotional symptom score during three clinic visits (18.1 vs. 14.2; mean change -3.8; 95% CI -5.7 to -1.9; P < 0.001), with greatest improvement in symptom scores for the five most severe symptoms (each P < 0.001). Follow-up of these 80 patients to final RSC visit (median 13.0 months) showed sustained reduction in mean combined physical and emotional symptom score (18.1 vs. 14.4; mean change -3.7; 95% CI -5.6 to -1.7; P < 0.001). These changes occurred without change in dialysis delivery.

CONCLUSION

RSC intervention that focuses on symptom control and patient-centered care is associated with improved total and individual symptom burden in dialysis patients. This supports a role for RSC as a management adjunct in these patients.

Complex arts-based interventions for patients receiving haemodialysis: A realist review

Many patients with end-stage kidney disease require haemodialysis, a treatment that requires attending hospital three times a week for four hours each visit. This treatment impacts profoundly on mental health. Arts-based interventions for patients receiving haemodialysis could address the impact of this treatment; however, there is no consensus on methods of implementation and mechanisms underlying these interventions in specific clinical contexts. Using a realist approach, relevant articles were synthesised to inform theory relating to the mechanism and implementation of complex arts-based interventions for haemodialysis patients. The theoretical framework includes two implementation phases, firstly delivery of person-centred art activities during haemodialysis and secondly, display of completed artwork. This intervention triggers mechanisms including flow and social capital. Implementation is hindered by constraints of the haemodialysis unit and patients' lack of confidence in their artistic skills. These issues can be addressed through aflexible approach to implementation and support from healthcare professionals.

A comparative descriptive analysis of perceived quality of caring attitudes and behaviours between haemodialysis patients and their nurses

Aim

Despite its importance in nursing, perceived quality of the nurse-patient relationship has seldom been researched. This study sought to examine and compare the quality of caring attitudes and behaviours as perceived by haemodialysis patients and their nurses.

Design

This comparative descriptive study involved 140 haemodialysis patients and 101 nurses caring for them in ten haemodialysis units in the French-speaking part of Switzerland.

Methods

Participants completed a sociodemographic questionnaire and the Caring Nurse-Patient Interaction Scale (CNPI-70).

Results

Both nurses and patients reported a high frequency of caring attitudes and behaviours. Patients gave higher ratings than nurses did on all the caring dimensions, except spirituality. Implications are discussed.

Routinely measuring symptom burden and health-related quality of life in dialysis patients: first results from the Dutch registry of patient-reported outcome measures

Background

The use of patient-reported outcome measures (PROMs) is becoming increasingly important in healthcare. However, incorporation of PROMs into routine nephrological care is challenging. This study describes the first experience with PROMs in Dutch routine dialysis care.

Methods

A pilot study was conducted in dialysis patients in 16 centres. Patients were invited to complete PROMs at baseline and 3 and 6 months. PROMs consisted of the 12-item short-form and Dialysis Symptom Index to assess health-related quality of life (HRQoL) and symptom burden. Response rates, HRQoL and symptom burden scores were analysed. Qualitative research methods were used to gain insight into patients’ views on using PROMs in clinical practice.

Results

In total, 512 patients (36%) completed 908 PROMs (24%) across three time points. Response rates varied from 6 to 70% among centres. Mean scores for physical and mental HRQoL were 35.6 [standard deviation (SD) 10.2] and 47.7 (SD 10.6), respectively. Patients experienced on average 10.8 (SD 6.1) symptoms with a symptom burden score of 30.7 (SD 22.0). Only 1–3% of the variation in PROM scores can be explained by differences between centres. Patients perceived discussing their HRQoL and symptom scores as insightful and valuable. Individual feedback on results was considered crucial.

Conclusions

The first results show low average response rates with high variability among centres. Dialysis patients experienced a high symptom burden and poor HRQoL. Using PROMs at the individual patient level is suitable and may improve patient–professional communication and shared decision making. Further research is needed to investigate how the collection and the use of PROMs can be successfully integrated into routine care to improve healthcare quality and outcomes.

LIFE AFTER HEMODIALYSIS

ABSTRACT Objective: to know the problems people face as a consequence of chronic kidney disease and their hemodialysis treatment. Method: a qualitative, exploratory and descriptive study with 12 people who were undergoing hemodialysis in a reference hospital. Semi-structured interviews were carried out at the people’s homes from September to December 2018. Data were analyzed according to directed content analysis, starting with identification of codes, which were later grouped into subcategories and categories. Results: people experienced significant changes in their lives after starting hemodialysis, presenting problems derived from treatment that were faced in order to maintain their lifestyle or resigning themselves to living abandoning aspects that gave them pleasure. The importance of maintaining power of will to continue treatment was appreciated, added to the acceptance process that was different for each person. Finally, a familiarity with death was evidenced due to frequent exposure to it through the death of hemodialysis colleagues, causing preparation for it. Conclusions: change in people’s lives as a result of disease and treatment is a complex situation for which they must mobilize personal tools that entail great efforts, living an acceptance process that can take years. Attention by health professionals must achieve closeness, empathy, humanity in treatment to promote own resources that favor personal well-being.

Diaphragmatic dysfunction associates with dyspnoea, fatigue, and hiccup in haemodialysis patients: a cross-sectional study

Muscle wasting is associated with increased mortality and morbidity in chronic kidney disease (CKD) patients, especially in the haemodialysis (HD) population. Nevertheless, little is known regarding diaphragm dysfunction in HD patients. We conducted a cross-sectional study at the Institute of Nephrology, Southeast University, involving 103 HD patients and 103 healthy volunteers as normal control. Ultrasonography was used to evaluate diaphragmatic function, including diaphragm thickness and excursion during quiet and deep breathing. HD patients showed lower end-inspiration thickness of the diaphragm at total lung capacity (0.386 ± 0.144 cm vs. 0.439 ± 0.134 cm, p < 0.01) and thickening fraction (TF) (0.838 ± 0.618 vs. 1.127 ± 0.757; p < 0.01) compared to controls. The velocity and excursion of the diaphragm were significantly lower in the HD patients during deep breathing (3.686 ± 1.567 cm/s vs. 4.410 ± 1.720 cm/s, p < 0.01; 5.290 ± 2.048 cm vs. 7.232 ± 2.365 cm; p < 0.05). Changes in diaphragm displacement from quiet breathing to deep breathing (△m) were lower in HD patients than in controls (2.608 ± 1.630 vs. 4.628 ± 2.110 cm; p < 0.01). After multivariate adjustment, diaphragmatic excursion during deep breathing was associated with haemoglobin level (regression coefficient = 0.022; p < 0.01). We also found that the incidence of dyspnoea and hiccup and the fatigue scores, all of which were related to diaphragmatic dysfunction, were significantly higher in HD patients than in controls (all p < 0.01). Improving diaphragm function through targeted therapies may positively impact clinical outcomes in HD patients.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Patient-reported outcome measures and their utility in the management of patients with advanced chronic kidney disease

Symptom and quality of life (QOL) measures in patients with advanced chronic kidney disease are recognized indicators of patient-centred care and represent important research, quality and clinical measures. This study examined relationships between symptom burden, QOL and functional status and associations of symptoms and mortality risk. A multisite longitudinal cohort analysis was undertaken in chronic kidney disease stage 4/5 (no dialysis) and dialysis patients. Patients completed symptom and QOL measures (Palliative Care Outcome Symptom Score renal), World Health Organisation QOL Brief Version) and Karnofsky Performance scale. Clinical and demographic data were recorded.

Treating symptoms to improve the quality of life in patients on chronic hemodialysis

Health-related quality of life (HRQOL) in patients on chronic hemodialysis has not improved significantly in the last 20 years. This is largely due to their substantial symptom burden which is rarely assessed and treated in routine clinical practice. This is also consequence of the lack of an appropriate armamentarium for the treatments of such symptoms. Adequate studies on the causes and pathogenesis of the symptoms of hemodialysis patients are needed followed by high-quality studies on possible therapeutic pharmacological and non-pharmacological interventions. Patients on chronic hemodialysis deserve a better quality of life.

Implementing an arts-based intervention for patients with end-stage kidney disease whilst receiving haemodialysis: a feasibility study protocol

BACKGROUND

End-stage kidney disease is a life-changing illness. Many patients require haemodialysis, a treatment that impacts profoundly on quality of life and mental health. Arts-based interventions have been used in other healthcare settings to improve mental health and quality of life; therefore, they may help address the impact of haemodialysis by improving these outcomes. However, there is a lack of evidence assessing their effectiveness in this population and few randomised controlled trials (RCTs) evaluating the effectiveness of complex arts-based interventions.

METHODS

The aims of this study are to establish the feasibility of a cluster RCT of an arts-based intervention for patients with end-stage kidney disease whilst receiving haemodialysis through a cluster randomised pilot study, explore the acceptability of the intervention with a process evaluation and explore the feasibility of an economic evaluation. The study will have three phases. The first phase consists of a cluster randomised pilot study to establish recruitment, participation and retention rates. This will involve the recruitment of 30 participants who will be randomly allocated through cluster randomisation according to shift pattern to experimental and control group. The second phase will be a qualitative process evaluation to establish the acceptability of the intervention within a clinical setting. This will involve semi-structured interviews with 13 patients and three focus groups with healthcare professionals. The third phase will be a feasibility economic evaluation to establish the best methods for data collection within a future cluster RCT.

DISCUSSION

Arts-based interventions have been shown to improve quality of life in healthcare settings, but there is a lack of evidence evaluating arts-based interventions for patients receiving haemodialysis. This study aims to assess the feasibility of a future cluster RCT assessing the impact of an arts-based intervention on the wellbeing and mental health of patients receiving haemodialysis and identify the key factors leading to successful implementation. The hope is this study will inform a trial that can influence future healthcare policy by providing robust evidence for arts-based interventions within the haemodialysis setting.

TRIAL REGISTRATION

The trial was prospectively registered on clinicaltrials.gov on 14/8/2018, registration number NCT03629496.

Primary health care decision making in pre-dialysis chronic kidney disease

OBJECTIVES

This qualitative descriptive study explored the primary health care decisions of a group of 12 Australians in Stages 3B to 5 with chronic kidney disease in the preservation of kidney health.

METHODS

Questioning within the qualitative interviews focused on gaining an understanding of the participants' perceptions of their kidney health and the decisions made as a consequence of their interaction within the Australian primary health care system.

RESULTS

Participants were dependent on their General Practitioner to recognise their symptoms, make the correct diagnosis and authorise the correct referral for specialist nephrology care. Three pathways in this process were identified: 'easy'; 'difficult' and 'protracted'. Clinician failure to correctly attribute symptoms to chronic kidney disease influenced the 'difficult' pathway, while failure to adequately communicate kidney health status influenced the 'protracted' pathway. Use of the language of 'recovery', 'stability' and 'protection' held meaning to the participants in gaining an understanding of their kidney health.

DISCUSSION

Identifying pathways to diagnosis and referral can raise awareness of the challenges kidney health consumers face in their participation within the primary health care arena. Using consumer meaningful language improves the capacity of these consumers to engage in their own primary health care agenda.

Symptom Cluster Science in Chronic Kidney Disease: A Literature Review

The purpose of this review was to synthesize evidence on symptom clusters in patients with chronic kidney disease (CKD). The quality of studies was evaluated using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Twelve articles met inclusion criteria. Patients had CKD ranging from Stages 2 through 5. Most studies determined clusters using variable-centered approaches based on symptoms; however, one used a person-centered approach based on demographic and clinical characteristics. The number of clusters identified ranged from two to five. Several clusters were prominent across studies including symptom dimensions of fatigue/energy/sleep, neuromuscular/pain, gastrointestinal, skin, and uremia; however, individual symptoms assigned to clusters varied widely. Several clusters correlated with patient outcomes, including health-related quality of life and mortality. Identifying symptom clusters in CKD is a nascent field, and more research is needed on symptom measures and statistical methods for clustering. The clinical implications of symptom clusters remain unclear.

Validation of the IPOS-Renal Symptom Survey in Advanced Kidney Disease: A Cross-sectional Study

CONTEXT

The significant symptom burden in advanced renal disease is often poorly recognized by clinicians. Recently, the Integrated Palliative Outcome Score (IPOS)-renal survey was developed from pre-existing tools to capture these symptoms and other common concerns.

OBJECTIVES

We studied the validity and reliability of the IPOS-renal survey (patient and staff versions) in an Australian population.

METHODS

Adult patients with advanced renal disease and nurses caring for them were participated. We initially administered the IPOS-renal survey simultaneously with other validated surveys and then retested the IPOS-renal after seven to 14 days. We tested the construct validity of 1) IPOS-renal patient version in relation to the Edmonton Symptom Assessment Survey-revised and the Kidney Diseases quality of life-short form version 1.3 questionnaire and 2) IPOS-renal staff version in relation to the Support Team Assessment Schedule survey.

RESULTS

Eighty-one patients (65 hemodialysis, 10 peritoneal dialysis, and six on supportive care; average age 64.9 years) and 53 nurses (average renal nursing experience 10.9 years) were participated. Intraclass coefficients for test-retest reliability were >0.7 for most queries; Cronbach's alphas for internal consistency were 0.84 (patient version) and 0.91 (staff version). In tests of construct validity, Spearman's coefficient of correlation between surveys and their comparators for similar questions was significant, at 0.61 to 0.77 (patients) and 0.24 to 0.76 (staff). As expected, symptom scores and total symptom burden were negatively correlated with summary scores of quality of life.

CONCLUSION

The IPOS-renal surveys, patient and staff versions, have good test-retest reliability, internal consistency, and construct validity in patients with advanced kidney disease and their nurses. We recommend their use in symptom assessment.

Qi deficiency is associated with depression in chronic hemodialysis patients

OBJECTIVE

Depression is a common bio-psycho-social problem in hemodialysis (HD) patients. Traditional Chinese medicine has been used for symptom management in patients with depression. Identification of the specific constitution in traditional Chinese medicine is critical for personalized care. However, the association between depression and specific constitution in HD patients is unknown.

METHODS

We conducted a cross-sectional study in all chronic HD patients (HD for more than 3 months) at China Medical University Hospital in Taiwan. The depression symptom severity was determined using the Beck Depression Inventory II (BDI-II). Clinical patterns in Chinese medicine were determined using the Constitution in Chinese Medicine Questionnaire. The association between constitution and depression was analyzed using logistic regression.

RESULTS

We recruited 467 chronic hemodialysis patients, including 219 females and 248 males, with a mean age of 63±12years. The mean duration of HD was 5.8 years. The mean score for the BDI-II was 11 (interquartile range 8-14). The major constitution was Yang-deficiency (43.7%) among these chronic HD patients. Qi-deficiency was correlated with a duration of HD of more than 5.8 years (p=0.04). Qi-deficiency [odds ratio (OR): 4.05, 95% confidence interval (CI): 1.69-9.72, p<0.01] was also associated with depression in logistic regression with adjustments for confounders, including calcium, phosphorus and hemoglobin levels.

CONCLUSION

Qi-deficiency constitution in Chinese medicine is associated with depression in chronic HD patients. Further studies are needed to determine whether treating Qi-deficiency integrating Chinese medicine treatment can improve patients' depression symptoms.