Fostering Innovation in Symptom Management among Hemodialysis Patients: Paths Forward for Insomnia, Muscle Cramps, and Fatigue

Patient-Centered Quality Measures for Dialysis Care: A Report of a Kidney Disease Outcomes Quality Initiative (KDOQI) Scientific Workshop Sponsored by the National Kidney Foundation

Providing high-quality patient-centered care is the central mission of dialysis facilities. Assessing quality and patient-centeredness of dialysis care is necessary for continuous dialysis facility improvement. Based predominantly on readily measured items, current quality measures in dialysis care emphasize biochemical and utilization outcomes, with very few patient-reported items. Additionally, current metrics often do not account for patient preferences and may compromise patient-centered care by limiting the ability of providers to individualize care targets, such as dialysis adequacy, based on patient priorities rather than a fixed numerical target. Developing, implementing, and maintaining a quality program using readily quantifiable data while also allowing for individualization of care targets that emphasize the goals of patients and their care partners provided the motivation for a September 2022 Kidney Disease Outcomes Quality Initiative (KDOQI) Workshop on Patient-Centered Quality Measures for Dialysis Care. Workshop participants focused on 4 questions: (1) What are the outcomes that are most important to patients and their care partners? (2) How can social determinants of health be accounted for in quality measures? (3) How can individualized care be effectively addressed in population-level quality programs? (4) What are the optimal means for collecting valid and robust patient-reported outcome data? Workshop participants identified numerous gaps within the current quality system and favored a conceptually broader, but not larger, quality system that stresses highly meaningful and adaptive measures that incorporate patient-centered principles, individual life goals, and social risk factors. Workshop participants also identified a need for new, low-burden tools to assess patient goals and priorities.

Randomized Controlled Trial of the Effect of an Exercise Rehabilitation Program on Symptom Burden in Maintenance Hemodialysis: A Clinical Research Protocol

Background

People receiving hemodialysis experience high symptom burden that contributes to low functional status and poor health-related quality of life. Management of symptoms is a priority for individuals receiving hemodialysis but limited effective treatments exist. There is emerging evidence that exercise programming can improve several common dialysis-related symptoms.

Objective

The primary aim of this study is to evaluate the effect of an exercise rehabilitation program on symptom burden in individuals receiving maintenance hemodialysis.

Design

Multicenter, randomized controlled, 1:1 parallel, open label, prospective blinded end point trial.

Setting

Three facility-based hemodialysis units in Winnipeg, Manitoba, Canada.

Participants

Adults aged 18 years or older with end-stage kidney disease receiving facility-based maintenance hemodialysis for more than 3 months, with at least 1 dialysis-related symptom as indicated by the Dialysis Symptom Index (DSI) severity score >0 (n = 150).

Intervention

Supervised 26-week exercise rehabilitation program and 60 minutes of cycling during hemodialysis thrice weekly. Exercise intensity and duration were supervised and individualized by the kinesiologist as per participant baseline physical function with gradual progression over the course of the intervention.

Control

Usual hemodialysis care (no exercise program).

Measurements

Our primary outcome is change in symptom burden at 12 weeks as measured by the DSI severity score. Secondary outcomes include change in modified DSI severity score (includes 10 symptoms most plausible to improve with exercise), change in DSI severity score at 26 and 52 weeks; time to recover post-hemodialysis; health-related quality of life measured using EuroQol (EQ)-5D-5L; physical activity behavior measured by self-report (Godin-Shepherd questionnaire) and triaxial accelerometry; exercise capacity (shuttle walk test); frailty (Fried); self-efficacy for exercise; and 1-year hospitalization and mortality.

Methods

Change in primary outcome will be compared between groups by independent 2-tailed t test or Mann-Whitney U test depending on data distribution and using generalized linear mixed models, with study time point as a random effect and adjusted for baseline DSI score. Similarly, change in secondary outcomes will be compared between groups over time using appropriate parametric and nonparametric statistical tests depending on data type and distribution.

Limitations

The COVID-19 pandemic restrictions on clinical research at our institution delayed completion of target recruitment and prevented collection of accelerometry and physical function outcome data for 15 months until restrictions were lifted.

Conclusions

The application of an exercise rehabilitation program to improve symptom burden in individuals on hemodialysis may ameliorate common symptoms observed in individuals on hemodialysis and result in improved quality of life and reduced disability and morbidity over the long term. Importantly, this pragmatic study, with a standardized exercise intervention that is adaptable to baseline physical function, addresses an important gap in both clinical care of hemodialysis patients and our current knowledge.

The Association Between Intradialytic Symptom Clusters and Recovery Time in Patients Undergoing Maintenance Hemodialysis: An Exploratory Analysis

Background

Individuals receiving hemodialysis often experience concurrent symptoms during treatment and frequently report feeling unwell after dialysis. The degree to which intradialytic symptoms are related, and which specific symptoms may impair health-related quality of life (HRQoL) is uncertain.

Objectives

To explore intradialytic symptoms clusters, and the relationship between intradialytic symptom clusters with dialysis treatment recovery time and HRQoL.

Design/setting

We conducted a post hoc analysis of a prospective cohort study of 118 prevalent patients receiving hemodialysis in two centers in Calgary, Alberta and Hamilton, Ontario, Canada.

Participants

Adults receiving hemodialysis treatment for at least 3 months, not scheduled for a modality change within 6 weeks of study commencement, who could provide informed consent and were able to complete English questionnaires independently or with assistance.

Methods

Participants self-reported the presence (1 = none to 5 = very much) of 10 symptoms during each dialysis treatment, the time it took to recover from each treatment, and weekly Kidney Disease Quality of Life 36-Item-Short Form (KDQoL-36) assessments. Principal component analysis identified clusters of intradialytic symptoms. Mixed-effects, ordinal and linear regression examined the association between symptom clusters and recovery time (categorized as 0, >0 to 2, >2 to 6, or >6 hours), and the physical component and mental component scores (PCS and MCS) of the KDQoL-36.

Results

One hundred sixteen participants completed 901 intradialytic symptom questionnaires. The most common symptom was lack of energy (56% of treatments). Two intradialytic symptom clusters explained 39% of the total variance of available symptom data. The first cluster included bone or joint pain, muscle cramps, muscle soreness, feeling nervous, and lack of energy. The second cluster included nausea/vomiting, diarrhea and chest pain, and headache. The first cluster (median score: -0.56, 25th to 75th percentile: -1.18 to 0.55) was independently associated with longer recovery time (odds ratio [OR] 1.62 per unit difference in score, 95% confidence interval [CI]: 1.23-2.12) and decreased PCS (-0.72 per unit difference in score, 95% CI: -1.29 to -0.15) and MCS scores (-0.82 per unit difference in score, 95% CI: -1.48 to -0.16), whereas the second cluster was not (OR 1.24, 95% CI: 0.97-1.58; PCS 0.19, 95% CI -0.46 to 0.83; MCS -0.72, 95% CI: -1.50 to 0.06).

Limitations

This was an exploratory analysis of a small data set from 2 centers. Further work is needed to externally validate these findings to confirm intradialytic symptom clusters and the generalizability of our findings.

Conclusions

Intradialytic symptoms are correlated. The presence of select intradialytic symptoms may prolong the time it takes for a patient to recover from a dialysis treatment and impair HRQoL.

Exercise Rehabilitation for People With End-Stage Kidney Disease: Who Will Fill the Gaps?

Exercise rehabilitation is a well established therapy for reducing morbidity and mortality and improving quality of life and function across chronic conditions. People with dialysis-dependent kidney failure have a high burden of comorbidity and symptoms, commonly characterised as fatigue, dyspnoea, and the inability to complete daily activities. Despite more than 30 years of exercise research in people with kidney disease and its established benefit in other chronic diseases, exercise programs are rare in kidney care and are not incorporated into routine management at any stage. In this review, we describe the mechanisms contributing to exercise intolerance in those with end-stage kidney disease and outline the role of exercise rehabilitation in addressing the major challenges to kidney care: cardiovascular disease, symptom burden, and physical frailty. We also draw on existing models of exercise rehabilitation from other chronic conditions to inform the way forward and challenge the status quo of exercise rehabilitation in both practice and research.

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

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

Managing the symptom burden associated with maintenance dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

Individuals with kidney failure undergoing maintenance dialysis frequently report a high symptom burden that can interfere with functioning and diminish life satisfaction. Until recently, the focus of nephrology care for dialysis patients has been related primarily to numerical targets for laboratory measures, and outcomes such as cardiovascular disease and mortality. Routine symptom assessment is not universal or standardized in dialysis care. Even when symptoms are identified, treatment options are limited and are initiated infrequently, in part because of a paucity of evidence in the dialysis population and the complexities of medication interactions in kidney failure. In May of 2022, Kidney Disease: Improving Global Outcomes (KDIGO) held a Controversies Conference-Symptom-Based Complications in Dialysis-to identify the optimal means for diagnosing and managing symptom-based complications in patients undergoing maintenance dialysis. Participants included patients, physicians, behavioral therapists, nurses, pharmacists, and clinical researchers. They outlined foundational principles and consensus points related to identifying and addressing symptoms experienced by patients undergoing dialysis and described gaps in the knowledge base and priorities for research. Healthcare delivery and education systems have a responsibility to provide individualized symptom assessment and management. Nephrology teams should take the lead in symptom management, although this does not necessarily mean taking ownership of all aspects of care. Even when options for clinical response are limited, clinicians should focus on acknowledging, prioritizing, and managing symptoms that are most important to individual patients. A recognized factor in the initiation and implementation of improvements in symptom assessment and management is that they will be based on locally existing needs and resources.

Peer support interventions in patients with kidney failure: A systematic review

BACKGROUND

Peer support has been associated with improved health-related outcomes (e.g., psychological well-being and treatment adherence) among patients with serious, chronic conditions, including kidney disease. Yet, there is little existing research evaluating the effects of peer support programs on health outcomes among patients with kidney failure being treated with kidney replacement therapy.

METHODS

Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, we conducted a systematic review using five databases to assess the effects of peer support programs on health-related outcomes (e.g., physical symptoms, depression) among patients with kidney failure undergoing kidney replacement therapy.

RESULTS

Peer support in kidney failure was assessed across 12 studies (eight randomized controlled trials, one quasi-experimental controlled trial, and three single-arm trials) with 2893 patients. Three studies highlighted the links between peer support and improved patient engagement with care, while one found peer support did not significantly impact engagement. Three studies showed associations between peer support and improvements in psychological well-being. Four studies underscored the effects of peer support on self-efficacy and one on treatment adherence.

CONCLUSIONS

Despite preliminary evidence of the positive associations between peer support and health-related outcomes among patients with kidney failure, peer support programs for this patient population remain poorly understood and underutilized. Further rigorous prospective and randomized studies are needed to evaluate how peer support can be optimized and incorporated into clinical care for this vulnerable patient population.

Patient Perspectives of Skeletal Muscle Cramping in Dialysis: A Focus Group Study

Key Points

This first step demonstrated content validity for a patient-reported outcome measure for skeletal muscle cramping in dialysis. This work lays the foundation for developing a patient-reported outcome measure for regulatory use to assess skeletal muscle cramping in people receiving dialysis.

Background

Skeletal muscle cramping is a common, painful, and debilitating symptom experienced by people receiving dialysis. Neither a standardized, patient-endorsed definition of skeletal muscle cramping nor full understanding of patients' perspectives of skeletal muscle cramping exist. We conducted focus groups, within a Kidney Health Initiative (KHI) project, to elicit skeletal muscle cramping experiences of people receiving dialysis as the basis for patient-reported outcome measure (PROM) development.

Methods

Eligible participants (English-speaking adults aged 18–85 years treated by dialysis and a skeletal muscle cramping episode within 30 days) were purposively recruited from a panel (L&E Research) of people receiving dialysis at home or in-center. Standard qualitative methods were used to conduct virtual 90-minute sessions discussing the following: skeletal muscle cramping clinical characteristics, participants' skeletal muscle cramping experiences, and feedback on a draft skeletal muscle cramping definition and a patient-facing conceptual model developed by the KHI project workgroup. We used qualitative thematic analysis.

Results

There were 20 diverse participants in three focus groups. Universally experienced skeletal muscle cramping attributes differed by dialysis setting in onset, worst pain rating, duration, and timing. Variably experienced attributes (applied to home and in-center dialysis) were gross and fine motor effect, sleep disruption, mood-related themes of fear, and annoyance/frustration/irritability. Avoidance/adaptive behaviors included reluctance or avoiding movement, adjusting what they ate or drink (e.g. , yellow mustard, pickles, pickle juice, and tonic water), heat application, massage, and cannabidiol use. The skeletal muscle cramping definition was endorsed, and insightful suggestions for conceptual model were collected.

Conclusions

This qualitative study of in-center and home patients' skeletal muscle cramping experiences identified universally and variably experienced attributes. The patient-endorsed skeletal muscle cramping definition can serve as a standard for assessment. These results provide the foundation to develop a PROM for regulatory use with people receiving maintenance dialysis who experience skeletal muscle cramping.

Exploration of symptom clusters during hemodialysis and symptom network analysis of older maintenance hemodialysis patients: a cross-sectional study

BACKGROUND

Symptom networks can provide empirical evidence for the development of personalized and precise symptom management strategies. However, few studies have established networks of symptoms experienced by older patients on maintenance hemodialysis. Our goal was to examine the type of symptom clusters of older maintenance hemodialysis patients during dialysis and construct a symptom network to understand the symptom characteristics of this population.

METHODS

The modified Dialysis Symptom Index was used for a cross-sectional survey. Network analysis was used to analyze the symptom network and node characteristics, and factor analysis was used to examine symptom clusters.

RESULTS

A total of 167 participants were included in this study. The participants included 111 men and 56 women with a mean age of 70.05 ± 7.40. The symptom burdens with the highest scores were dry skin, dry mouth, itching, and trouble staying asleep. Five symptom clusters were obtained from exploratory factor analysis, of which the clusters with the most severe symptom burdens were the gastrointestinal discomfort symptom cluster, sleep disorder symptom cluster, skin discomfort symptom cluster, and mood symptom cluster. Based on centrality markers, it could be seen that feeling nervous and trouble staying asleep had the highest strength, and feeling nervous and feeling irritable had the highest closeness and betweenness.

CONCLUSIONS

Hemodialysis patients have a severe symptom burden and multiple symptom clusters. Dry skin, itching, and dry mouth are sentinel symptoms in the network model; feeling nervous and trouble staying asleep are core symptoms of patients; feeling nervous and feeling irritable are bridge symptoms in this symptom network model. Clinical staff can formulate precise and efficient symptom management protocols for patients by using the synergistic effects of symptoms in the symptom clusters based on sentinel symptoms, core symptoms, and bridge symptoms.

Sickness Symptoms in Kidney Transplant Recipients: A Scoping Review

Sickness symptoms (depressive symptoms, anxiety, and fatigue) are common among people with chronic illness, often presenting as a symptom cluster. Sickness symptoms persist in many patients with chronic kidney disease, even after kidney transplantation (KT); however, little is known about sickness symptom-induced burden in KT recipients. This scoping review synthesizes available evidence for sickness symptoms in KT recipients, including findings on symptom prevalence, predictors, outcomes, interrelationships, and clustering. Among 38 reviewed studies, none identified sickness symptoms as a cluster, but we observed interrelationships among the symptoms examined. Fatigue was the most prevalent sickness symptom, followed by anxiety and depressive symptoms. Predictors of these symptoms included demographic, clinical, and psychosocial factors, and health-related quality of life was the most researched outcome. Future research should use common data elements to phenotype sickness symptoms, include biological markers, and employ sophisticated statistical methods to identify potential clustering of sickness symptoms in KT recipients.

"You need a team": perspectives on interdisciplinary symptom management using patient-reported outcome measures in hemodialysis care-a qualitative study

BACKGROUND

Patient-reported outcome measures (PROMs) are standardized instruments used for assessing patients' perspectives on their health status at a point in time, including their health-related quality of life, symptoms, functionality, and physical, mental, and social wellbeing. For people with kidney failure receiving hemodialysis, addressing high symptom burden and complexity relies on care team members integrating their expertise to achieve common management goals. In the context of a program-wide initiative integrating PROMs into routine hemodialysis care, we aimed to explore patients' and clinicians' perspectives on the role of PROMs in supporting interdisciplinary symptom management.

METHODS

We employed a qualitative descriptive approach using semi-structured interviews and observations. Eligible participants included adult patients receiving intermittent, outpatient hemodialysis for > 3 months, their informal caregivers, and hemodialysis clinicians (i.e., nurses, nephrologists, and allied health professionals) in Southern Alberta, Canada. Guided by thematic analysis, team members coded transcripts in duplicate and developed themes iteratively through review, refinement, and discussion.

RESULTS

Thirty-three clinicians (22 nurses, 6 nephrologists, 5 allied health professionals), 20 patients, and one caregiver participated in this study. Clinicians described using PROMs to coordinate care across provider types using the resources available in their units, whereas patients tended to focus on the perceived impact of this concerted care on symptom trajectory and care experience. We identified 3 overarching themes with subthemes related to the role of PROMs in interdisciplinary symptom management in this setting: (1) Integrating care for interrelated symptoms ("You need a team", conducive setting, role clarity and collaboration); (2) Streamlining information sharing and access (symptom data repository, common language for coordinated care); (3) Reshaping expectations (expectations for follow-up, managing symptom persistence).

CONCLUSIONS

We found that use of PROMs in routine hemodialysis care highlighted symptom interrelatedness and complexity and helped to streamline involvement of the interdisciplinary care team. Issues such as role flexibility and resource constraints may influence sustainability of routine PROM use in the outpatient hemodialysis setting.

Five-Year Symptom Trajectories in Nondialysis-Dependent CKD Patients

BACKGROUND AND OBJECTIVES

Late stages of CKD are characterized by significant symptom burden. This study aimed to identify subgroups within the 5-year trajectories of symptom evolution in patients with CKD and to describe associated patient characteristics and outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 2787 participants (66% men) with eGFR <60 ml/min per 1.73 m2 enrolled in the CKD-Renal Epidemiology and Information Network (CKD-REIN) cohort study from July 2013 to May 2016, we assessed symptoms annually using the Kidney Disease Quality of Life-36 (KDQOL-36) questionnaire until December 2020. A total of 9121 measures were reported over follow-up; all participants had symptoms scored for at least one time point. We used a joint latent class-mixed model to distinguish profiles of symptom trajectories.

RESULTS

Patient mean age (±SD) at baseline was 67±13 years, and mean eGFR was 33±13 ml/min per 1.73 m2. The prevalence of each symptom ranged from 24% (chest pain) to 83% (fatigue), and 98% of participants reported at least one symptom. After a median (interquartile range) follow-up of 5.3 (3.4-6.0) years, 690 participants initiated KRT, and 490 died before KRT. We identified two profiles of symptom trajectories: a "worse symptom score and worsening trajectory" in 31% of participants, characterized by a low initial symptom score that worsened more than ten points over time, and a "better symptom score and stable trajectory" in 69% of participants, characterized by a high initial score that remained stable. Participants in the worse symptom score and worsening trajectory group had more risk factors for CKD progression at baseline, worse quality of life, and a higher risk of KRT and death before KRT than other participants.

CONCLUSIONS

This study highlights a significant worsening of symptoms in about one third of the participants, whereas the majority reported low symptom severity throughout the study.

Higher Symptom Frequency and Severity After the Long Interdialytic Interval in Patients on Maintenance Intermittent Hemodialysis

Introduction

Patients on intermittent hemodialysis (HD) have a high symptom burden. Though studies report higher hospitalizations and mortality after the long interdialytic interval, whether symptoms vary based on the interdialytic interval is unclear.

Methods

This is a prospective observational study of patients over the age of 18 who received in-center HD. Patients were surveyed on the presence and severity of 20 different symptoms at the end of 12 HD sessions. Wilcoxon signed-rank test was used for comparison of severity for each symptom by the interval. Multivariable generalized estimating equation with Poisson regression by repeated measure method was used to determine the association of interdialytic interval and symptom frequency while adjusting for potential confounders.

Results

From the 97 patients enrolled, the most common symptoms were fatigue (60.8%), cramping (58.8%), and dry skin (52.6%). There was large variability in the frequency of symptoms, ranging 0% to 8% of treatments. The most severe symptoms were bone pain (mean severity score 2.2±0.9) and diarrhea (mean severity score 2.2±0.7). Eight of the 20 symptoms were significantly more common after the long interdialytic interval including fatigue (22% vs. 15%, P < 0.001) and cramping (21% vs. 16%, P = 0.003). The long interval had a 37% higher incidence rate for symptoms compared to the short interval even after adjustment. Results were similar across genders.

Conclusion

Symptoms are more common after the long interdialytic interval. Clinical assessment and research evaluating patient symptoms need to be cognizant of when patients are surveyed or include the length of interdialytic interval as a confounding variable.

Efficacy, Safety, and Tolerability of Oral Furosemide Among Patients Receiving Hemodialysis: A Pilot Study

Introduction

Diuretic use may reduce volume-related complications in hemodialysis. We evaluated the efficacy, safety, and tolerability of furosemide in patients with hemodialysis-dependent kidney failure.

Methods

We conducted an open label, single-arm, 18-week, dose titration pilot study of oral furosemide (maximum dose 320 mg/day) among patients receiving maintenance hemodialysis who reported at least 1 cup of urine output per day. The primary efficacy outcome was an increase from baseline to a specified threshold of 24-hour urine volume, with the threshold based on baseline urine volume (<200 ml/day vs. ≥200 ml/day). Safety outcomes included hypokalemia and hypomagnesemia, and tolerability was assessed by prespecified patient-reported symptoms.

Results

Of the 39 participants, 28 (72%) received the expected furosemide dose, 3 (8%) underwent dose reduction, 5 (12%) discontinued furosemide without dose reduction, and 3 (8%) underwent dose reduction and subsequently discontinued furosemide. The median (quartile 1, quartile 3) baseline 24-hour urine volume was 290 ml (110, 740), and the maximum, average daily study furosemide dose ranged from 69 mg/day to 320 mg/d. The urine output efficacy outcome was met by 12 (33%), 11 (33%), and 7 (22%) participants at weeks 5, 12, and 18, respectively, in the intention-to-treat analysis, and by 12 (39%), 9 (35%), and 7 (28%) participants at weeks 5, 12, and 18, respectively, in the on-treatment analysis. There were no electrolyte, furosemide level, or patient-reported hearing change safety events.

Conclusion

Furosemide was generally safe and well tolerated, but only one-third of participants met the efficacy definition at week 5. The clinical importance of the efficacy findings is uncertain.

Peter WL, Logan D, Tentori F, Keller S, West M, Lacson E. Conceptual Framework for Patient-Reported Outcome Measures in Clinical Trials of Skeletal Muscle Cramping Experienced in Dialysis: A Kidney Health Initiative Workgroup Report

Skeletal muscle cramping is a common and bothersome symptom for patients on maintenance dialysis therapy, regardless of modality, and it has not been prioritized for innovative assessments or treatments. Research to prevent or treat skeletal muscle cramping in patients receiving dialysis is hindered by poorly understood pathophysiology, lack of an accepted definition, and the absence of a standardized measurement method. The Kidney Health Initiative, a public-private partnership between the American Society of Nephrology and US Food and Drug Administration, convened a multidisciplinary workgroup to define a set of patient-reported outcome measures for use in clinical trials to test the effect of new dialysis devices, new KRTs, lifestyle/behavioral modifications, and medications on skeletal muscle cramping. Upon determining that foundational work was necessary, the workgroup undertook a multistep process to elicit concepts central to developing the basis for demonstrating content validity of candidate patient-reported outcome measures for skeletal muscle cramping in patients on dialysis. The workgroup sought to (1) create an accepted, patient-endorsed definition for skeletal muscle cramping that applies to all dialysis modalities, (2) construct a conceptual model for developing and evaluating a skeletal muscle cramping-specific patient-reported outcome measure, and (3) identify potential questions from existing patient-reported outcome measures that could be modified or adapted and subsequently tested in the dialysis population. We report the results of the workgroup's efforts, provide our recommendations, and issue a call to action to address the gaps in knowledge and research needs we identified. These action steps are urgently needed to quantify skeletal muscle cramping burden, assess the effect, and measure meaningful changes of new interventions to improve the experience of patients receiving dialysis and suffering from skeletal muscle cramping.

Living Well With Kidney Disease and Effective Symptom Management: Consensus Conference Proceedings

Chronic kidney disease (CKD) confers a high burden of uremic symptoms that may be underrecognized, underdiagnosed, and undertreated. Unpleasant symptoms, such as CKD-associated pruritus and emotional/psychological distress, often occur within symptom clusters, and treating 1 symptom may potentially alleviate other symptoms in that cluster. The Living Well with Kidney Disease and Effective Symptom Management Consensus Conference convened health experts and leaders of kidney advocacy groups and kidney networks worldwide to discuss the effects of unpleasant symptoms related to CKD on the health and well-being of those affected, and to consider strategies for optimal symptom management. Optimizing symptom management is a cornerstone of conservative and preservative management which aim to prevent or delay dialysis initiation. In persons with kidney dysfunction requiring dialysis (KDRD), incremental transition to dialysis and home dialysis modalities offer personalized approaches. KDRD is proposed as the preferred term given the negative connotations of "failure" as a kidney descriptor, and the success stories in CKD journeys. Engaging persons with CKD to identify and prioritize their personal values and individual needs must be central to ensure their active participation in CKD management, including KDRD. Person-centered communication and care are required to ensure diversity, equity, and inclusion; education/awareness that considers the health literacy of persons with CKD; and shared decision-making among the person with CKD, care partners, and providers. By putting the needs of people with CKD, including effective symptom management, at the center of their treatment, CKD can be optimally treated in a way that aligns with their goals.

The legacy effect of a home walking exercise program in kidney failure patients on dialysis

BACKGROUND

The EXCITE trial (JASN 28: 1259-1268, 2017) in dialysis patients showed that a 6-month home walking exercise program improves physical function and two dimensions of the KDQOLSF-SF™ questionnaire. Whether improvements in physical function achieved by exercise interventions are maintained in the long term has never been tested in the dialysis population.

METHODS

In this post-trial study embedded in the EXCITE trial we tested the response to the 6MWT and the 5STS tests and the KDQOLSF-SF™ from the 6th month (end of the trial) to the 36th month.

RESULTS

Among the 227 patients of the EXCITE trial cohort, 162 underwent at least three out four testing visits (baseline, 6, 18 and/or 36 month) contemplated by the study protocol and 89 all four testing visits. In the primary analysis by the linear mixed model the gain in walking distance achieved at 6th month in the exercise group (between-arms difference: +36 meters, 95% CI: 22-51, P < 0.001) was maintained at the 18th month (between-arms difference: +37 meters, 95% CI: 19-57, P < 0.001) to reduce to 23 meters (95% CI: -4 to 49 meters, P = 0.10) at 36th month. Overall, the post trial difference in walking distance trajectories between the two study arms was highly significant (P = 0.004). Furthermore, the walking distance changes at the 6th (r = 0.34, P = 0.018) and 18th month (r = 0.30, P = 0.043) were directly related with number of structured exercise sessions completed during the trial (i.e. the first 6 months). No such an effect was registered in the response to the 5STS or in quality of life as measured by the KDQOLSF-SF™.

CONCLUSIONS

In dialysis patients the benefits of a 6-months structured walking program outlast the duration of the intervention and postpone the loss of walking performance which naturally occurs in this population but does not affect QoL and the response to the STS test.

Emerging Treatments for Insomnia, Sleep Apnea, and Restless Leg Syndrome Among Dialysis Patients

Sleep disturbances are highly prevalent in patients with predialysis chronic kidney disease, end-stage kidney disease, and after a kidney transplant. They contribute to impairment in daily function and are associated with a high burden of physical and psychiatric symptoms, decreased quality of life, and increased morbidity and mortality. Sleep disturbances also may precipitate and accelerate kidney disease progression. They often evolve across the spectrum of kidney dysfunction and may persist or re-emerge in kidney transplant recipients. Investigation into the multifaceted and dynamic relationships between sleep disturbance and chronic kidney disease requires consideration of myriad contributors including the progression of kidney disease itself, the role of treatment via dialysis and kidney transplant, psychosocial factors, and underlying sleep disorders. Despite sleep disturbance being identified as a priority to address by patients and caregivers, sleep disorders including insomnia, sleep apnea, and restless leg syndrome remain under-recognized and undertreated, and innovation in their management remains modest. In this article, we review the relationships between sleep disturbance and kidney disease, the impact of sleep disturbance and sleep disorders on symptom burden and mental health, and treatment opportunities that may address overlapping symptoms across the spectrum of kidney disease and that could improve patient-related and clinical outcomes.

Patient-centred approaches for the management of unpleasant symptoms in kidney disease

Patients with chronic kidney disease (CKD) frequently experience unpleasant symptoms. These can be gastrointestinal (constipation, nausea, vomiting and diarrhoea), psychological (anxiety and sadness), neurological (lightheadedness, headache and numbness), cardiopulmonary (shortness of breath and oedema), dermatological (pruritus and dry skin), painful (muscle cramps, chest pain and abdominal pain) or involve sexual dysfunction, sleep disorders and fatigue. These symptoms often occur in clusters, with one of them as the lead symptom and others as secondary symptoms. Uraemic toxins (also called uremic toxins) are often considered to be the main cause of CKD-associated symptom burden, but treatment of uraemia by dialysis often fails to resolve them and can engender additional symptoms. Indeed, symptoms can be exacerbated by comorbid conditions, pharmacotherapies, lifestyle and dietary regimens, kidney replacement therapy and ageing. Patients with kidney disease, including those who depend on dialysis or transplantation, should feel actively supported in their symptom management through the identification and targeting of unpleasant symptoms via a tailored palliative care approach. Such an approach may help minimize the burden and consequences of kidney disease, and lead to improved patient outcomes including health-related quality of life and better life participation.

Kidney Disease Symptoms before and after Kidney Transplantation

BACKGROUND AND OBJECTIVES

Patients with kidney failure report a high symptom burden, which likely increases while on dialysis due to physical and mental stressors and decreases after kidney transplantation due to restoration of kidney function.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We leveraged a two-center prospective study of 1298 kidney transplant candidates and 521 recipients (May 2014 to March 2020). Symptom scores (0-100) at evaluation and admission for transplantation were calculated using the Kidney Disease Quality of Life Short-Form Survey, where lower scores represent greater burden, and burden was categorized as very high: 0.0-71.0; high: 71.1-81.0; medium: 81.1-91.0; and low: 91.1-100.0. We estimated adjusted waitlist mortality risk (competing risks regression), change in symptoms between evaluation and transplantation (n=190), and post-transplantation symptom score trajectories (mixed effects models).

RESULTS

At evaluation, candidates reported being moderately to extremely bothered by fatigue (32%), xeroderma (27%), muscle soreness (26%), and pruritus (25%); 16% reported high and 21% reported very high symptom burden. Candidates with very high symptom burden were at greater waitlist mortality risk (adjusted subdistribution hazard ratio, 1.67; 95% confidence interval, 1.06 to 2.62). By transplantation, 34% experienced an increased symptom burden, whereas 42% remained unchanged. The estimated overall symptom score was 82.3 points at transplantation and 90.6 points at 3 months (10% improvement); the score increased 2.75 points per month (95% confidence interval, 2.38 to 3.13) from 0 to 3 months, and plateaued (-0.06 points per month; 95% confidence interval, -0.30 to 0.18) from 3 to 12 months post-transplantation. There were early (first 3 months) improvements in nine of 11 symptoms; pruritus (23% improvement) and fatigue (21% improvement) had the greatest improvements.

CONCLUSIONS

Among candidates, very high symptom burden was associated with waitlist mortality, but for those surviving and undergoing kidney transplantation, symptoms improved.

Clinical impact of patient-centered care for hemodialysis patients using routine assessment of symptom burden

The study aimed to verify the impact of our clinical strategy, which emphasizes patient-centered care, based on patient-reported outcome measures (PROMs) results in hemodialysis patients. We developed our original PROM (comprising 20 items) to assess patients' symptom burden. To confirm the validity of our clinical pattern, we performed various analyses using PROM data. We retrospectively enrolled 383 individuals (mean age 66.3 years; 252 men), collected their PROM data in December 2013, and followed them up for 3 years. We noted a lower mortality rate and a lower prevalence of itching in our facilities than in previous surveys and reports in Japan. Furthermore, we observed that the severity of symptom burden affected medium-term prognosis. This is the first study to report the results of patient-centered medical practice utilizing PROMs in dialysis care. Careful attention should be paid to patients' symptom burden, as performed in objective data management.

Application of a Computerized Decision Support System to Develop Care Strategies for Elderly Hemodialysis Patients

In this paper, the strategy of elderly haemodialysis patients' care is analysed by the computer's decision system to conduct an in-depth research machine. Maintenance haemodialysis patients have a high demand for continuation care, and healthcare workers should provide personalized and specialized seamless continuation care services for patients according to patients' needs, by reasonably using the hospital, community, and other health resources and with the help of emerging network technologies, such as information platforms and wearable devices to prolong the survival period of patients and improve their self-management ability and quality of life. The service provision and compensation strategy of the combined healthcare model should be optimized to improve the health protection of the elderly and promote health equity. On the one hand, it should target strengthening the service provision of healthcare integration, guide the elderly to reasonably choose the healthcare integration model, and pay attention to the spiritual and cultural needs and end-of-life care services for the elderly. On the other hand, we should expand the financing channels of medical insurance, optimize the design of compensation mechanisms, explore the role of health risk sharing, and accelerate the development of long-term care insurance, independent of basic medical insurance. The reliability of the scale was found to be 0.916 for the total Cronbach alpha coefficient, 0.798-0.919 for each dimension, and 0.813 for the fold-half reliability of the scale; the validity indicated that the correlation coefficient range of each article day with the total scale score was 0.27-0.72, and the correlation coefficient range of each dimension with the total scale was 0.56-0.72. The validation factor analysis was used to verify the structure of the scale. The validation factor analysis indexes met the fitting criteria after correction. The model fitted better with the actual model after correction, indicating that the scale has good reliability.

The effect of aromatherapy on fatigue in adults receiving haemodialysis treatment: A systematic review and meta-analysis of randomised controlled trials

AIM

To synthesise the effect of aromatherapy on fatigue in adults receiving haemodialysis treatment in randomised controlled trials.

DESIGN

A systematic review and meta-analysis of randomised controlled trials following the Cochrane methods.

DATA RESOURCES

Systematic search was carried out using the Cochrane Library, CINAHL, Council of Higher Education National Thesis Center, Networked Digital Library of Theses & Dissertations, Science Direct, Springer Link, Scopus, PubMed, ProQuest, Ovid, ULAKBIM Turkish National Databases and Web of Science without year limitation for studies published in the English language. The review covered the period between 1960 and April 2020.

REVIEW METHODS

Three authors reviewed the risk of bias independently and systematically using the Cochrane Collaboration tool.

RESULTS

Eight studies with 606 participants were included in this systematic review and meta-analysis. Aromatherapy was applied through inhalation and massage methods and performed from 2 to 30 min and in 3 to 30 sessions. There was no significant publication bias. Aromatherapy had a large effect on fatigue in adults receiving haemodialysis treatment and high heterogeneity.

CONCLUSION

Aromatherapy has a high and positive effect on fatigue in the adults receiving haemodialysis and can be used as an effective intervention in the management of fatigue.

IMPACT

Aromatherapy may help to reduce the severity of fatigue in adults receiving haemodialysis. The findings of this systematic review and meta-analysis will contribute to the use of aromatherapy in the management of fatigue and conduction of randomised controlled trials related to aromatherapy.

Screening for symptoms of anxiety and depression in patients treated with renal replacement therapy: utility of the Edmonton Symptom Assessment System-Revised

PURPOSE

The Edmonton Symptom Assessment System-revised (ESASr) is widely used in clinical oncology to screen for physical and emotional symptoms. The performance of the anxiety and depression items (ESASr-A and ESASr-D, respectively) as screening tools have not been evaluated in patients treated with renal replacement therapy.

METHODS

Kidney transplant recipients and patients on dialysis were recruited in Toronto. Patients were classified as having moderate/severe depression and anxiety symptoms using the established cut-off score of ≥ 10 on the Patient Health Questionnaire-9 (PHQ-9) and the General Anxiety Disorder-7 (GAD-7) questionnaires.

RESULTS

This study included 931 participants; 62% male, mean age (SD) 55(16), and 52% White. All participants completed ESASr, however only 748 participants completed PHQ-9 and 769 participants completed GAD-7. Correlation between ESASr item scores and legacy scores were moderately strong (ESASr-D/PHQ-9: 0.61; ESASr-A/GAD-7: 0.64). We found good discrimination for moderate/severe depression and anxiety [area under the receiver operating characteristics curve (95% CI) ESASr-D 0.82(0.78-0.86); ESASr-A 0.87 (0.82, 0.92)]. The cut-off ≥ 2 for ESASr-D [Sensitivity = 0.76; Specificity = 0.77; Likelihood Ratio (LR) + = 3.29; LR - = 0.31] and ≥ 4 for ESASr-A (Sensitivity = 0.75; Specificity = 0.87; LR + = 5.76; LR - = 0.29) had the best combination of measurement characteristics.

CONCLUSION

The identified ESASr-D and ESASr-A cut-off scores may be used to rule out patients without emotional distress with few false negatives. However, the low sensitivity identified in our analysis suggests that neither ESASr-D or ESASr-A are acceptable as standalone screening tools.

Development and testing of the hemodialysis symptom distress scale (HSD-22) to identify the symptom cluster by using exploratory factor analysis

BACKGROUND

Patients receiving hemodialysis (HD) often experience multiple symptoms concurrently and these symptoms may impact their quality of life. A valid and reliable tool is needed to assess the symptom distress of patients receiving HD in terms of the perspective of symptom clusters. Although many studies have explored symptom clusters related to patients receiving HD, the clusters formed had problems with overlapping, vagueness, lack of cluster-specificity, and difficulty in discerning their common mechanism under the cluster.

AIMS

To develop reliable measurement tool to identify the symptom clusters of patients undergoing HD.

DESIGN

A cross-sectional descriptive study.

METHODS

To examine the physiological properties of the HD symptom distress (HSD) scale, 216 participants were recruited from a HD center of a medical university hospital in southern Taiwan from February 2019 to April 2019. Construct validity was evaluated by exploratory factor analysis (EFA), and the internal consistency and test-retest reliability were estimated by Cronbach's alpha and intraclass correlation coefficient (ICC).

RESULTS

The CVI value of the HSD was 0.89. The HSD scale was composed of five factors with 22 items, including insufficient energy/vitality, cardiac-pulmonary distress, sleep disturbance, musculoskeletal distress, and gastrointestinal distress, with factor loading ranging from 0.62 to 0.87, explaining 65.5% of the total variance. Cronbach's alpha coefficient of the HSD total scale was 0.93, and five subscales ranged from 0.73 to 0.89. The test-retest reliability was 0.92 (p < 0.001) by using the intraclass correlation coefficient (ICC) for the HSD-22 scale.

CONCLUSION / IMPLICATION

Theoretical testing from our study indicated that the HSD-22 scale had satisfactory validity and reliability. Therefore, this assessment tool can be employed to identify the symptom clusters of patients receiving HD in the clinical setting. Such identification enables healthcare professionals to provide interventions to release patients' symptom distress efficiently.

Integrating Patient Priorities with Science by Community Engagement in the Kidney Precision Medicine Project

The Kidney Precision Medicine Project (KPMP) is a multisite study designed to improve understanding of CKD attributed to diabetes or hypertension and AKI by performing protocol-driven kidney biopsies. Study participants and their kidney tissue samples undergo state-of-the-art deep phenotyping using advanced molecular, imaging, and data analytical methods. Few patients participate in research design or concepts for discovery science. A major goal of the KPMP is to include patients as equal partners to inform the research for clinically relevant benefit. The purpose of this report is to describe patient and community engagement and the value they bring to the KPMP. Patients with CKD and AKI and clinicians from the study sites are members of the Community Engagement Committee, with representation on other KPMP committees. They participate in KPMP deliberations to address scientific, clinical, logistic, analytic, ethical, and community engagement issues. The Community Engagement Committee guides KPMP research priorities from perspectives of patients and clinicians. Patients led development of essential study components, including the informed consent process, no-fault harm insurance coverage, the ethics statement, return of results plan, a "Patient Primer" for scientists and the public, and Community Advisory Boards. As members across other KPMP committees, the Community Engagement Committee assures that the science is developed and conducted in a manner relevant to study participants and the clinical community. Patients have guided the KPMP to produce research aligned with their priorities. The Community Engagement Committee partnership has set new benchmarks for patient leadership in precision medicine research.

Effect of Aerobic Exercise on Dialysis-Related Symptoms in Individuals Undergoing Maintenance Hemodialysis: A Systematic Review and Meta-Analysis of Clinical Trials

BACKGROUND

Hemodialysis is associated with a high symptom burden that impairs health-related quality of life and functional status. Effective symptom management is a priority for individuals receiving hemodialysis. Aerobic exercise may be an effective, nonpharmacologic treatment for specific hemodialysis-related symptoms. This systematic review investigated the effect of aerobic exercise on hemodialysis-related symptoms in adults with kidney failure undergoing maintenance hemodialysis.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We searched MEDLINE, PubMed, Cochrane CENTRAL, CINAHL, PsycINFO, SPORTDiscus, EMBASE, PEDro, and Scopus databases from 1960 or inception until April 15, 2020 for randomized controlled trials investigating the effect of aerobic exercise on hemodialysis-related symptoms, identified as prespecified primary or secondary outcomes, as compared with controls in adults on maintenance hemodialysis. We identified restless legs syndrome as the primary outcome.

RESULTS

Of 3048 studies identified, 15 randomized controlled trials met the eligibility criteria. These studies investigated the effect of aerobic exercise on restless legs syndrome (two studies), sleep disturbance (four studies), anxiety (four studies), depression (nine studies), muscle cramping (one study), and fatigue (one study). Exercise interventions were intradialytic in ten studies and outside of hemodialysis in five studies. Heterogenous interventions and outcomes and moderate to high risk of bias precluded meta-analysis for most symptoms. Aerobic exercise demonstrated improvement in symptoms of restless legs syndrome, muscle cramping, and fatigue, as compared with nonexercise controls. Meta-analysis of depressive symptoms in studies using the Beck Depression Inventory demonstrated a greater reduction in Beck Depression Inventory score with exercise as compared with control (mean difference -7.57; 95% confidence interval, -8.25 to -6.89).

CONCLUSIONS

Our review suggests that in adults on maintenance hemodialysis, aerobic exercise improves several hemodialysis-related symptoms, including restless legs syndrome, symptoms of depression, muscle cramping, and fatigue. However, the use of validated outcome measures with demonstrated reliability and responsiveness in more diverse hemodialysis populations is required to fully characterize the effect of this intervention.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

PROSPERO #CRD42017056658.

A Narrative Review of Management Strategies for Common Symptoms in Advanced CKD

Patients with advanced chronic kidney disease (CKD) experience multiple bothersome symptoms, undermining their quality of life (QOL). With growing attention to the importance of symptom management in advanced CKD, the evidence regarding symptoms is increasing. In this review, we briefly summarize the current evidence of effective pharmacologic and nonpharmacologic interventions to improve symptoms and QOL in patients with advanced CKD, including those on dialysis. We focused on symptoms that are commonly experienced by patients, such as pain, fatigue, sleep disturbances, itching, nausea and vomiting, cognitive impairment, and anxiety and depression. We noted that research in symptom science focused on improving symptom management in CKD is still very limited. In addition to the lack of clinical practice guidelines to address those common symptoms, the major gaps in the current literature include the evidence regarding mechanistic pathways to inform the development of effective symptom management for CKD populations, the evidence to confirm effective pharmacologic interventions in other populations for CKD populations, and research on how to incorporate effective symptom management approaches into clinical care. Although improving mortality remains as an important area in the kidney community, there is an urgent need to focus on improving symptom management to improve QOL in advanced CKD.

Fatigue characteristics on dialysis and non-dialysis days in patients with chronic kidney failure on maintenance hemodialysis

BACKGROUND

Fatigue is prevalent in hemodialysis patients who for survival follow a strict dialysis treatment regimen - dialysis and non-dialysis days. As a result, the daily activities, symptom burden, and clinical outcomes of hemodialysis patients vary significantly between dialysis and non-dialysis days. Fatigue is one of the most reported debilitating symptoms by hemodialysis patients with profound negative impact on their quality of life. Prior studies assessed fatigue during the preceding 7 or 30 days and did not discriminate fatigue characteristics between dialysis and non-dialysis days. We aimed to characterize and compare fatigue severity and fatigue interference with daily activities between dialysis and non-dialysis days.

METHODS

Hemodialysis patients self-reported fatigue on consecutive dialysis and non-dialysis days using the 9-item Brief Fatigue Inventory. The differences in fatigue characteristics between dialysis and non-dialysis days were analyzed using one-way ANCOVA.

RESULTS

Global fatigue burden was worse on a dialysis day compared to a non-dialysis day (P for all < 0.001). Age and education were associated with fatigue, but hemodialysis-related variables were not. A significant inverse association of physical activity with fatigue severity observed on non-dialysis day; there was also a negative association between the normalized protein catabolic rate and fatigue severity on both dialysis and non-dialysis days. The positive association of depression with fatigue severity and fatigue interference were consistent on both dialysis and non-dialysis days. None of these factors, however, explained differences in fatigue characteristics between dialysis and non-dialysis days.

CONCLUSIONS

Fatigue, measured in severity and interference, was more pronounced on a dialysis day relative to a non-dialysis day. These differences were not explained by age, sex, education, hemodialysis-related variables, habitual exercise, nutritional status, and or depression. The quantitative measures of fatigue characteristics may facilitate future interventional trials design and better fatigue management for hemodialysis patients.

The benefits of Qigong exercise for symptoms of fatigue: A protocol for systematic review and meta-analysis

BACKGROUND

About 5% to 20% of the general population suffers from continuous fatigue, which is also one of the most frequent symptoms seen in primary medical care. Fatigue, if not effectively relieved, may have an adverse effect on the quality of life and treatment of patients. Qigong is a safe and comfortable exercise popular in China and among the Ethnic Chinese, and is a complementary therapy used to treat fatigue, such as cancer related fatigue and chronic fatigue syndrome. It appears promising but lacks convincing evidence; thus, necessitating further investigation.

METHODS

Eight databases (PubMed, Web of Science, Embase, Cochrane Library, China Biology Medicine disc, China National Knowledge Infrastructure, WanFang and VIP Data Knowledge Service Platform) will be searched from inception to November 30, 2020 for randomized controlled trials published in English or Chinese investigating the outcomes of the Qigong exercise (QE) for symptoms of fatigue and quality of life. We will also include additional references of relevant published studies by manually retrieving reference lists of included literature and previous relevant reviews. For articles that meet the inclusion criteria, 2 reviewers will independently conduct the study selection, data extraction, and risk of bias assessment. The results of the outcome measures will be reported in risk ratios for dichotomous data and standard mean differences for continuous data. If necessary, we will also perform subgroup analyses and analyze the causes.

RESULTS

The results of this review will be submitted to a journal for publication.

CONCLUSION

This systematic review protocol aims to analyze whether QE is effective in treating fatigue associated with various disease.

REGISTRATION

INPLASY2020110133.

Zolpidem Versus Trazodone Initiation and the Risk of Fall-Related Fractures among Individuals Receiving Maintenance Hemodialysis

BACKGROUND AND OBJECTIVES

Zolpidem, a nonbenzodiazepine hypnotic, and trazodone, a sedating antidepressant, are the most common medications used to treat insomnia in the United States. Both drugs have side effect profiles (e.g., drowsiness, dizziness, and cognitive and motor impairment) that can heighten the risk of falls and fractures. Despite widespread zolpidem and trazodone use, little is known about the comparative safety of these medications in patients receiving hemodialysis, a vulnerable population with an exceedingly high fracture rate.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using data from the United States Renal Data System registry (2013-2016), we conducted a retrospective cohort study to investigate the association between the initiation of zolpidem versus trazodone therapy and the 30-day risk of hospitalized fall-related fractures among Medicare-enrolled patients receiving maintenance hemodialysis. We used an active comparator new-user design and estimated 30-day inverse probability of treatment-weighted hazard ratios and risk differences. We treated death as a competing event.

RESULTS

A total of 31,055 patients were included: 18,941 zolpidem initiators (61%) and 12,114 trazodone initiators (39%). During the 30-day follow-up period, 101 fall-related fractures occurred. Zolpidem versus trazodone initiation was associated with a higher risk of hospitalized fall-related fracture (weighted hazard ratio, 1.71; 95% confidence interval, 1.11 to 2.63; weighted risk difference, 0.17%; 95% confidence interval, 0.07% to 0.29%). This association was more pronounced among individuals prescribed higher zolpidem doses (hazard ratio, 1.85; 95% confidence interval, 1.10 to 3.01; and risk difference, 0.20%; 95% confidence interval, 0.04% to 0.38% for higher-dose zolpidem versus trazodone; and hazard ratio, 1.60; 95% confidence interval, 1.01 to 2.55 and risk difference, 0.14%; 95% confidence interval, 0.03% to 0.27% for lower-dose zolpidem versus trazodone). Sensitivity analyses using longer follow-up durations yielded similar results.

CONCLUSIONS

Among individuals receiving maintenance hemodialysis, zolpidem initiators had a higher risk of hospitalized fall-related fracture compared with trazodone initiators.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020_12_18_CJN10070620_final.mp3.

Novel conservative management of chronic kidney disease via dialysis-free interventions

PURPOSE OF REVIEW

In advanced chronic kidney disease (CKD) patients with progressive uremia, dialysis has traditionally been the dominant treatment paradigm. However, there is increasing interest in conservative and preservative management of kidney function as alternative patient-centered treatment approaches in this population.

RECENT FINDINGS

The primary objectives of conservative nondialytic management include optimization of quality of life and treating symptoms of end-stage renal disease (ESRD). Dietetic-nutritional therapy can be a cornerstone in the conservative management of CKD by reducing glomerular hyperfiltration, uremic toxin generation, metabolic acidosis, and phosphorus burden. Given the high symptom burden of advanced CKD patients, routine symptom assessment using validated tools should be an integral component of their treatment. As dialysis has variable effects in ameliorating symptoms, palliative care may be needed to manage symptoms such as pain, fatigue/lethargy, anorexia, and anxiety/depression. There are also emerging treatments that utilize intestinal (e.g., diarrhea induction, colonic dialysis, oral sorbents, gut microbiota modulation) and dermatologic pathways (e.g., perspiration reduction) to reduce uremic toxin burden.

SUMMARY

As dialysis may not confer better survival nor improved patient-centered outcomes in certain patients, conservative management is a viable treatment option in the advanced CKD population.

Auricular Acupressure for Insomnia in Patients With Maintenance Hemodialysis: A Systematic Review and Meta-Analysis

Background: Insomnia is one of the common problems in patients with maintenance hemodialysis (MHD). Previous studies have reported the beneficial effects of auricular acupressure (AA) for insomnia in patients with MHD. This study aimed to critically evaluate the efficacy and safety of AA for insomnia in patients with MHD. Methods: Web of Science, Embase, PubMed, Cochrane Library, Chinese Biomedical Database, Wanfang Data, Chinese Science and Technology Periodicals database, and China National Knowledge Infrastructure were systematically searched from inception to April 30, 2020, to identify any eligible randomized controlled trials. MHD patients with insomnia were included regardless of age, gender, nationality, or race. The experimental interventions included AA alone or AA combined with other therapies. The control interventions included placebo, no treatment, or other therapies. The primary outcome was sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI). RevMan 5.3 software was used for statistical analysis. Results: Eight studies involving 618 participants were included for statistical analysis. A meta-analysis showed no significant difference of PSQI global score after 8 weeks of AA treatment compared with estazolam (p = 0.70). Other narrative analyses revealed that PSQI global score was significantly attenuated after AA treatment in comparison with mental health education (p = 0.03, duration of 4 weeks; p = 0.02, duration of 8 weeks), AA plus routine nursing care compared with routine nursing care alone (p < 0.0001), and AA plus footbath compared with footbath alone (p = 0.01), respectively. A meta-analysis showed that AA could significantly increase the response rate (reduction of PSQI global score by 25% and more) in comparison with estazolam (p = 0.01). Other narrative analyses reported that the response rate was significantly increased after AA treatment compared with sham AA (p = 0.02), AA compared with mental health education (p = 0.04), and AA plus routine nursing care compared with routine nursing care alone (p = 0.0003), respectively. Conclusion: The present findings suggest that AA may be an alternative treatment for insomnia in patients with MHD. However, more large-scale, high-quality trials are still warranted to confirm these outcomes.

Pain management in patients with chronic kidney disease and end-stage kidney disease

PURPOSE OF REVIEW

This review evaluates current recommendations for pain management in chronic kidney disease (CKD) and end-stage kidney disease (ESKD) with a specific focus on evidence for opioid analgesia, including the partial agonist, buprenorphine.

RECENT FINDINGS

Recent evidence supports the use of physical activity and other nonpharmacologic therapies, either alone or with pharmacological therapies, for pain management. Nonopioid analgesics, including acetaminophen, topical analgesics, gabapentinoids, serotonin-norepinephrine reuptake inhibitors, and TCA may be considered based on pain cause and type, with careful dose considerations in kidney disease. NSAIDs may be used in CKD and ESKD for short durations with careful monitoring. Opioid use should be minimized and reserved for patients who have failed other therapies. Opioids have been associated with increased adverse events in this population, and thus should be used cautiously after risk/benefit discussion with the patient. Opioids that are safer to use in kidney disease include oxycodone, hydromorphone, fentanyl, methadone, and buprenorphine. Buprenorphine appears to be a promising and safer option due to its partial agonism at the mu opioid receptor.

SUMMARY

Pain is poorly managed in patients with kidney disease. Nonpharmacological and nonopioid analgesics should be first-line approaches for pain management. Opioid use should be minimized with careful monitoring and dose adjustment.

Sleep-HD trial: short and long-term effectiveness of existing insomnia therapies for patients undergoing hemodialysis

BACKGROUND

Patients with end-stage kidney disease (ESKD) treated with hemodialysis (HD) experience many distressing symptoms. One frequently reported symptom is insomnia. There are unique issues about HD treatments and schedules that disrupt regular sleep/wake routines and possibly contribute to the high severity of insomnia. Despite evidence for broad-ranging health effects of insomnia, very few clinical trials have tested the efficacy of treatments for HD patients. Cognitive-behavioral therapy for insomnia (CBT-I) is a recommended first-line therapy but largely inaccessible to HD patients in the United States, partly because they commit considerable amounts of time to thrice-weekly dialysis treatments. Another important reason could be the logistical and reimbursement challenges associated with providing behavioral health care at the dialysis center. CBT-I delivered by telehealth can overcome barriers to access, but its efficacy has never been rigorously tested for these patients. Pharmacotherapy is the most widely used treatment for insomnia; however, some drugs presently used are unsafe as they are associated with a higher risk for death for HD patients (benzodiazepines and zolpidem-like drugs). The efficacy and safety of other medications (trazodone) for the treatment of insomnia has never been tested for patients treated with HD.

METHODS

This trial tests the short- and long-term comparative effectiveness of 6-week treatment with telehealth CBT-I, trazodone, or medication placebo. This will be accomplished with a randomized controlled trial (RCT) in which 126 participants treated with HD in community-based dialysis facilities with chronic insomnia will be assigned 1:1:1 to telehealth CBT-I, trazodone, or medication placebo, respectively; short-term effectiveness of each treatment arm will be determined at the end of 6-weeks of treatment and long-term effectiveness at 25-weeks. The primary and secondary patient-reported outcomes will be assessed with computer-based telephone interviewing by research scientists blinded to treatment assignment; additional secondary outcomes will be assessed by participant interview and actigraphy.

DISCUSSION

This clinical RCT will provide the first evidence for the comparative effectiveness of two distinct approaches for treating chronic insomnia and other patient-reported outcomes for patients receiving maintenance HD.

TRIAL REGISTRATION

NCT03534284 May 23, 2018. SLEEP-HD Protocol Version: 1.3.4 (7/22/2020).

A Critical Review of Exercise Training in Hemodialysis Patients: Personalized Activity Prescriptions Are Needed

Exercise training appears to have modest or inconsistent benefits in hemodialysis patients. This may be due to the low volume and intensity of exercise often prescribed. To address this, research is needed to evaluate the efficacy of individualized exercise prescriptions as a component of a comprehensive lifestyle intervention strategy that gives patients more autonomy to choose preferred types of physical activity.

Association between Palliative Care Consultation and Advance Palliative Care Rates: A Descriptive Cohort Study in Patients at Various Stages in the Continuum of Chronic Kidney Disease

Background: Despite evidence that advance care planning (ACP) benefits patients with serious illnesses, there is a dearth of information about "who" is referred for palliative care (PC) consultation, the rate of PC consultation, and the outcomes of referrals in patients with advanced chronic kidney disease/end-stage kidney disease (aCKD/ESKD). Objectives: (1) To describe patient characteristics associated with PC consultations and (2) to determine the frequency and outcome of PC consultation on documented ACP discussions for patients with aCKD/ESKD. Methodology/Design: This is retrospective observational electronic health record cohort review. Settings: University of Virginia (UVA) hospital, clinics, and dialysis units. Participants: Patients were studied along two time intervals. Time period January 1, 2015 to June 30, 2017 included all patients admitted to UVA during that time period with estimated glomerular filtration rate (eGFR) <60 mL/minute. Time period January 1, 2018 to March 31, 2019 included two cohorts: patients with eGFR <15 mL/minute who had died during study period excluding those who withdrew from dialysis and those who were dialysis dependent and withdrew from dialysis. Results: Aside from higher rates of PC consultation in patients with heart failure, none of the demographic and comorbidity data studied affected whether or not a patient is referred to PC in patients with aCKD/ESKD. PC consultation rates were low among all patients studied: 14.7% in patients with eGFR <60 mL/minute, 28.9% in dialysis patients withdrawing from dialysis, and 57.1% in terminally ill patients with eGFR <15 mL/minute. In all cohorts, PC consultations were associated with improved ACP. Conclusion: PC consultation is significantly associated with better end-of-life outcomes with more completion of ACP and hospice referral in patients with aCKD/ESKD. PC consultation rates remain low. Even in terminally ill patients with more aCKD, >40% were never seen by PC. Until policies and curricula better prepare nephrologists to independently address ACP, collaboration between nephrologists and PC specialists is recommended.

The current and future landscape of dialysis

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care.

The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care.

The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease.

Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life.

Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis.

Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators).

Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.

Prevalence and Persistence of Uremic Symptoms in Incident Dialysis Patients

Background

Uremic symptoms are major contributors to the poor quality of life among patients on dialysis, but whether their prevalence or intensity has changed over time is unknown.

Methods

We examined responses to validated questionnaires in two incident dialysis cohort studies, the Choices for Health Outcomes in Caring for ESRD (CHOICE) study (N=926, 1995-1998) and the Longitudinal United States/Canada Incident Dialysis (LUCID) study (N=428, 2011-2017). We determined the prevalence and severity of uremic symptoms-anorexia, nausea/vomiting, pruritus, sleepiness, difficulty concentrating, fatigue, and pain-in both cohorts.

Results

In CHOICE and LUCID, respectively, mean age of the participants was 58 and 60 years, 53% and 60% were male, and 28% and 32% were black. In both cohorts, 54% of the participants had diabetes. Median time from dialysis initiation to the symptoms questionnaires was 45 days for CHOICE and 77 days for LUCID. Uremic symptom prevalence in CHOICE did not change from baseline to 1-year follow-up and was similar across CHOICE and LUCID. Baseline symptom prevalence in CHOICE and LUCID was as follows: anorexia (44%, 44%, respectively), nausea/vomiting (36%, 43%), pruritus (72%, 63%), sleepiness (86%, 68%), difficulty concentrating (55%, 57%), fatigue (89%, 77%), and pain (82%, 79%). In both cohorts, >80% of patients had three or more symptoms and >50% had five or more symptoms. The correlation between individual symptoms was low (ρ<0.5 for all comparisons). In CHOICE, no clinical or laboratory parameter was strongly associated with multiple symptoms.

Conclusions

The burden of uremic symptoms among patients on dialysis is substantial and has not changed in the past 15 years. Improving quality of life will require identification of the factors that underlie the pathogenesis of uremic symptoms and better ways of removing the toxins that are responsible.

Physical activity for people with chronic kidney disease: an international survey of nephrologist practice patterns and research priorities

OBJECTIVES

People with chronic kidney diseases (CKD) have identified exercise as a research priority. To inform the research agenda, we surveyed nephrologists on their practice patterns, available resources and research priorities for exercise and physical activity (PA) in CKD.

DESIGN

Cross-sectional international survey.

SETTING AND PARTICIPANTS

19-item electronic survey was administered to practising nephrologists with publicly available email addresses in Canada (n=354) and Australia and New Zealand (ANZ) and via newsletters for the Australian and New Zealand Society of Nephrology (n=598).

OUTCOMES

Frequency and predictors of exercise and PA counselling in practice and research priorities.

RESULTS

189 respondents (20% response) completed the survey. Eighty-one per cent of ANZ and 42% of Canadian respondents reported that their renal programmes did not have any exercise programmes or resources. The most frequently reported barrier for exercise programme implementation was a lack of funding (77%). Ninety per cent of respondents thought regular exercise provides 'health benefits' for all CKD stages; 59% reported that exercise counselling was within the nephrologists' scope of practice and 47% reported 'frequently' or 'always' counselling patients. In multivariable analysis, female gender (OR 2.31; 95% CI 1.16 to 4.58) and older age (OR 1.94 per age category increase; 95% CI 1.15 to 3.26) were associated with exercise counselling. Out of 194 research priorities, 65 (34%) were clinical outcomes (cardiovascular parameters) and 30% were patient-reported outcomes (quality of life).

CONCLUSIONS

Most nephrologists consider exercise and PA counselling as within their scope of practice and beneficial but, due to competing priorities, do not regularly counsel patients. This suggests a need for the evaluation of effective and efficient counselling strategies and a role for the routine involvement of exercise specialists in kidney care. Cardiovascular parameters and quality of life were identified as important outcomes for future exercise trials.

Physical Symptom Cluster Subgroups in Chronic Kidney Disease

BACKGROUND

Symptom burden associated with chronic kidney disease can be debilitating, with a negative effect on patient health-related quality of life. Latent class clustering analysis is an innovative tool for classifying patient symptom experience.

OBJECTIVES

The aim of the study was to identify subgroups of patients at greatest risk for high symptom burden, which may facilitate development of patient-centered symptom management interventions.

METHODS

In this cross-sectional analysis, baseline data were analyzed from 3,921 adults enrolled in the Chronic Renal Insufficiency Cohort Study from 2003 to 2008. Latent class cluster modeling using 11 items on the Kidney Disease Quality of Life symptom profile was employed to identify patient subgroups based on similar observed physical symptom response patterns. Multinomial logistic regression models were estimated with demographic variables, lifestyle and clinical variables, and self-reported measures (Kidney Disease Quality of Life physical and mental component summaries and the Beck Depression Inventory).

RESULTS

Three symptom-based subgroups were identified, differing in severity (low symptom, moderate symptom, and high symptom). After adjusting for other variables in multinomial logistic regression, membership in the high-symptom subgroup was less likely for non-Hispanic Blacks and men. Other factors associated with membership in the high-symptom subgroup included lower estimated glomerular filtration rate, history of cardiac/cardiovascular disease, higher Beck Depression Inventory scores, and lower Kidney Disease Quality of Life physical and mental component summaries.

DISCUSSION

Three symptom subgroups of patients were identified among patients with mild-to-moderate chronic kidney disease. Several demographic and clinical variables predicted membership in subgroups. Further research is needed to determine if symptom subgroups are stable over time and can be used to predict healthcare utilization and clinical outcomes.

Trends and Racial Disparities of Palliative Care Use among Hospitalized Patients with ESKD on Dialysis

BACKGROUND

Study findings show that although palliative care decreases symptom burden, it is still underused in patients with ESKD. Little is known about disparity in use of palliative care services in such patients in the inpatient setting.

METHODS

To investigate the use of palliative care consultation in patients with ESKD in the inpatient setting, we conducted a retrospective cohort study using the National Inpatient Sample from 2006 to 2014 to identify admitted patients with ESKD requiring maintenance dialysis. We compared palliative care use among minority groups (black, Hispanic, and Asian) and white patients, adjusting for patient and hospital variables.

RESULTS

We identified 5,230,865 hospitalizations of such patients from 2006 through 2014, of which 76,659 (1.5%) involved palliative care. The palliative care referral rate increased significantly, from 0.24% in 2006 to 2.70% in 2014 (P<0.01). Black and Hispanic patients were significantly less likely than white patients to receive palliative care services (adjusted odds ratio [aOR], 0.72; 95% confidence interval [95% CI], 0.61 to 0.84, P<0.01 for blacks and aOR, 0.46; 95% CI, 0.30 to 0.68, P<0.01 for Hispanics). These disparities spanned across all hospital subtypes, including those with higher proportions of minorities. Minority patients with lower socioeconomic status (lower level of income and nonprivate health insurance) were also less likely to receive palliative care.

CONCLUSIONS

Despite a clear increase during the study period in provision of palliative care for inpatients with ESKD, significant racial disparities occurred and persisted across all hospital subtypes. Further investigation into causes of racial and ethnic disparities is necessary to improve access to palliative care services for the vulnerable ESKD population.