Renal Association Clinical Practice Guideline on Haemodialysis

Physical activity, exercise habits and health-related quality of life in maintenance hemodialysis patients: a multicenter cross-sectional study

BACKGROUND

Although exercise has the potential to yield numerous benefits for maintenance hemodialysis patients, the relationship between physical activity, exercise habits, and health-related quality of life (HRQOL) has not been thoroughly investigated. This study aimed to characterize the physical activity, exercise habits, and HRQOL of maintenance hemodialysis patients while examining the associations between these factors.

METHODS

A convenience sampling was used to recruit 827 patients from 74 dialysis units in China. The structured questionnaire included sociodemographics, the International Physical Activity Questionnaire, exercise habits, and the Kidney Disease Quality of Life Short Form 1.3. An independent samples t-test, multivariable logistic regression analysis, and multivariable linear regression analysis were used.

RESULTS

The physical activity levels of 69% of participants were found to be below the recommendation of the World Health Organization. Despite 62.4% of participants reporting regular exercise, 73.8% reported light exercise intensity, and 92.6% engaged in walking or jogging. Participants' HRQOL was higher in the low-intensity exercise group compared with the moderate-to-hard-intensity exercise group. Moderate-to-high physical activity was associated with better HRQOL in 13 of the 19 domains and regular exercise was linked to higher HRQOL in four of the 19 domains.

CONCLUSIONS

This study identified a low level of physical activity, light exercise intensity, and walking as the primary exercise type among the participants. A significant correlation was found between higher physical activity levels, regular exercise, and better HRQOL for maintenance hemodialysis patients. It is advisable to implement strategies to enhance physical activity levels and design exercise programs for maintenance hemodialysis patients based on their real-world physical activity levels and exercise habits.

A novel robust evaluation approach to improve systematic behavior of failure safety in water supply system under various ellipsoid uncertainties

This study proposes a novel robust optimization approach for an integrated water supply system, wherein the decision-makers attempt to improve failure safety of system under various uncertainty strategies. To cope with uncertainty, the ellipsoid uncertainty set is assumed to evaluate the best feasible solution in the direction of water supply under various strategies. We assessed the case of Hamoun watershed, a water-stressed watershed in southeastern of Iran, to evaluate the developed robust optimization model. In the following, the comparative feasibility under uncertainty levels is conducted to analyze the impacts of simulation strategies on the status of robust model. Based on the final results, the reliability of the model's objective functions experienced an increasing trend ( 58.3 % ), and the objective function values under the uncertainty strategies is greatly improved. The findings of the analysis show that the robust strategies in response to the failure safety achieve outstanding optimal objectives under uncertainty.

A practical review of barriers and challenges to a definitive randomised trial of grafts versus fistula

A definitive randomised controlled trial of arteriovenous fistula (AVF) versus arteriovenous grafts (AVG) has been advocated for more than a decade, but as yet, none has been completed. The aim of this article is to summarise the theoretical barriers, review the difficulties in trial design and practicalities that have thus far prevented this from occurring.

Impact of Difelikefalin on the Health-Related Quality of Life of Haemodialysis Patients with Moderate-To-Severe Chronic Kidney Disease-Associated Pruritus: A Single-Arm Intervention Trial

OBJECTIVE

Chronic kidney disease-associated pruritus (CKD-aP) can have a substantial negative impact on health-related quality of life (HRQoL), including an increased risk of depression, anxiety and sleep disturbance. This trial aimed to assess the impact of intravenous difelikefalin on HRQoL in haemodialysis patients with moderate-to-severe CKD-aP.

METHODS

Post hoc analysis of an open-label, multicentre, single-arm intervention trial assessed pruritus severity and HRQoL at baseline and at 12 weeks of difelikefalin treatment using Worst Itching Intensity Numerical Rating Scale (WI-NRS), Sleep Quality Numeric Rating Scale (SQ-NRS), 5-D itch scale, Skindex-10 scale, EQ-5D-5L with Pruritus Bolt-On (EQ-PSO).

RESULTS

A total of 222 patients received ≥ 1 dose of difelikefalin, and 197 patients completed 12 weeks of difelikefalin treatment. Clinically meaningful changes from baseline to 12 weeks were observed in all disease-specific measures: 73.7% of patients achieved a ≥ 3-point reduction in the weekly mean of 24 h WI-NRS scores and 66% of patients experienced ≥ 3-point improvements in SQ-NRS scores. Improvements were also observed in all Skindex-10 scale and 5-D itch scale domain scores. The percentage of patients reporting no problems in all EQ-PSO domains increased from 1.4 to 24.7% (p < 0.001), respectively. Patients' generic HRQoL EQ-5D-5L mean utility and EQ-5D visual analogue scale scores increased from baseline to 12 weeks: mean changes 0.04 (p = 0.001) and 2.8 (p = 0.046), respectively.

CONCLUSIONS

Patients undergoing haemodialysis with moderate-to-severe CKD-aP receiving difelikefalin reported experiencing clinically meaningful improvements in both their pruritus symptoms and itch-related QoL.

CLINICALTRIALS

gov registration number, NCT03998163; first submitted, 7 May 2019.

Prescribing the dialysis dose and treatment frequency in home haemodialysis

BACKGROUND

There is growing interest in home haemodialysis (HHD) performed with low-flow dialysate devices and variable treatment schedules. The target standard Kt/V (stdKt/V) should be 2.3 volumes/week, according to KDOQI guidelines (2015). The current formula for stdKt/V does not help prescribe the dialysis dose (eKt/V) and treatment frequency (TF). The aim of this study was to obtain a formula for stdKt/V that is able to define the minimum required values of eKt/V and TF to achieve the targeted stdKtV.

METHODS

Thirty-eight prevalent patients on HHD were enrolled. A total of 231 clinical datasets were available for urea modelling using the Solute-Solver software (SS), recommended by KDOQI guidelines. A new formula (stdKt/V = a + b × Kru + c × eKt/V) was obtained from multivariable regression analysis of stdKt/V vs eKt/V and residual kidney urea clearance (Kru). The values of coefficients a, b and c depend on the treatment schedules and the day of the week of blood sampling for the kinetic study (labdayofwk) and then vary for each of their foreseen 62 combinations. For practical purposes, we used only seven combinations, assuming Monday as a labdayofwk for each of the most common schedules of the 7 days of the week.

RESULTS

The stdKt/V values obtained with SS were compared with the paired ones obtained with the formula. The mean ± standard deviation stdKt/V values obtained with SS and the formula were 3.043 ± 0.530 and 2.990 ± 0.553, respectively, with 95% confidence interval +0.15 to -0.26. A 'prescription graph' was built using the formula to draw lines expressing the relationship between Kru and required eKt/V for each TF. Using this graph, TF could have been reduced from the delivered 5.8 ± 0.8 to 4.8 ± 0.8 weekly sessions.

CONCLUSIONS

The new formula for stdKtV is reliable and can support clinicians to prescribe the dialysis dose and TF in patients undergoing HHD.

Actioning the findings of hard endpoint clinical trials as they emerge in the realm of chronic kidney disease care: a review and a call to action

Fewer than half of patients treated with hemodialysis survive 5 years. Multiple therapeutics are used to address the complications of advanced chronic kidney disease but most have not been found to improve clinical outcomes. Clinical trials of treatment innovations for chronic kidney diseases and dialysis care have been suboptimal in number and quality. Recent trials are changing this trend. Practice and policy change when new evidence emerges remains frequently impeded by resource and organizational constraints and accordingly, clinical practice guidelines are updated years or decades after definitive evidence is produced. Ultimately, practice change in health systems is slow, leading to impaired uptake of effective medical interventions and lower value healthcare, although innovations in rapid guideline production are emerging. What can be done to ensure that conclusive evidence is taken up in practice, policy and healthcare funding? We use the example of the recently published hard endpoint study "Comparison of high-dose HDF with high-flux HD" (CONVINCE) (hemodiafiltration versus hemodialysis), to explain how a new trial can impact on medical knowledge and change in practices. We (i) assess how the trial can be placed in the context of the totality of the evidence, (ii) define whether or not further trials of convective dialysis therapies are still needed and (iii) examine whether the evidence for convective therapies is now ready to inform practice, policy and funding change. When looking at CONVINCE in the context of the totality of evidence, we show that it addresses dialysis quality improvement priorities and is consistent with other trials evaluating convective dialysis therapies, and that the evidence for convective dialysis therapies is now definitive. Once updated evidence for cost-effectiveness in specific healthcare settings and patient-reported outcomes become available, we should therefore determine whether or not clinical practice guidelines should recommend uptake of convective dialysis therapies routinely, and move on to evaluating other treatments.

Laboratory Monitoring of Heparin Anticoagulation in Hemodialysis: Rationale and Strategies

Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly used to prevent clotting of the hemodialysis extracorporeal circuit and optimize hemodialysis adequacy. There is no consensus on the optimal dosing for UFH and LMWHs during hemodialysis. In clinical practice, semiquantitative clotting scoring of the dialyzer and venous chamber may help to guide UFH and LMWH dose adjustment. Laboratory monitoring has not been shown to improve clinical outcomes and is therefore not routinely indicated in most hemodialysis patients. It might, however, be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding. Methods for laboratory monitoring include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs. Target ranges for anticoagulation in hemodialysis have been suggested but not clearly defined. When utilizing these tests, issues such as availability, standardization, interfering factors, and interpretation must be considered. In this narrative review, we discuss the rationale and methods of monitoring anticoagulation in hemodialysis.

How to Ensure Patency of the Extracorporeal Circuit in Hemodialysis: Global Perspectives

An adequate knowledge of anticoagulants used to prevent clotting in the extracorporeal circuit is crucial to provide optimal hemodialysis. Drugs can potentially prevent extracorporeal circuit clotting, but administration, half-life, and potential side effects differ. However, there is a lack of concise recommendations to guide anticoagulation and to avoid side effects. Because of the development of newer anticoagulant agents, direct thrombin inhibitors, and heparinoids, some of the side effects related to heparin may be overcome, but a deeper knowledge of these newer drugs is necessary. Moreover, types of heparin used, routes of administration, and health care economics vary around the world. We performed an extensive review of the literature, and the present article focuses on available anticoagulant drugs, exploring doses, side effects, particular use in hemodialysis, mechanism of action, pharmacokinetic properties, and use in special situations. Classical anticoagulants are still the standard of anticoagulation, but many questions remain unanswered; for example, is there real superiority of one treatment over another in terms of efficacy, safety, and health care economics? Anticoagulant protocols for hemodialysis need to be standardized and further studies performed to answer all of these questions.

Avoiding Systemic Heparinization During Hemodialysis: How the Dialysis Setup Might Help

Heparin is the most widely used anticoagulant for maintaining patency of the extracorporeal blood circuit during intermittent hemodialysis. Inadvertently, this leads to systemic heparinization of the patient. Repeated intermittent heparinization during hemodialysis has been associated with increased bleeding risks and metabolic and immunologic effects. Alternative strategies for minimizing systemic anticoagulation encompass dilution methods, regional citrate anticoagulation, priming of the extracorporeal circuit, and modifications to dialyzer membranes and dialysate composition. The effectiveness of these alternatives in maintaining patency of the extracorporeal circuit varies substantially. Although most studies have focused on particular changes in the hemodialysis setup, several combined interventions for adapting the hemodialysis setup are now being studied. This narrative review aims to present an overview of the current landscape of hemodialysis setup strategies aimed at limiting or avoiding systemic anticoagulation during treatment. Additionally, this review intends to shed light on the underlying pathophysiological mechanisms that contribute to variations observed in reported outcomes.

The effects of exercise training interventions on depression in hemodialysis patients

Purpose

Depression considerably influences the clinical outcomes, treatment compliance, quality of life, and mortality of hemodialysis patients. Exercise plays a beneficial role in depressive patients, but its quantitative effects remain elusive. This study aimed to summarize the effects of exercise training on depression in patients with end-stage renal disease undergoing hemodialysis.

Methods

The PUBMED, EMBASE, and Cochrane Library databases were systematically searched from inception to April 2023 to identify published articles reporting the effect of exercise training on the depression level of patients with End-Stage Renal Disease undergoing hemodialysis. Data were extracted from the included studies using predefined data fields by two independent researchers. The Cochrane Handbook for Systematic Reviews of Interventions and Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies were employed for quality evaluation.

Results

A total of 22 studies enrolling 1,059 patients who participated in exercise interventions were included. Hemodialysis patients exhibited superior outcomes with intradialytic exercise (SMD = -0.80, 95% CI: -1.10 to -0.49) and lower levels of depression following aerobic exercise (SMD = -0.93, 95%CI: -1.32 to -0.55) compared to combined exercise (c - 0.85, 95% CI: -1.29 to -0.41) and resistance exercise (SMD = -0.40, 95%CI: -0.96 to 0.17). Regarding exercise duration, patients manifested lower depression levels when engaging in exercise activities for a duration exceeding 6 months (SMD = -0.92, 95% CI: -1.67 to -0.17). Concerning the duration of a single exercise session, the most significant improvement was noted when the exercise duration exceeded 60 min (SMD = -1.47, 95% CI: -1.87 to -1.06).

Conclusion

Our study determined that exercise can alleviate depression symptoms in hemodialysis patients. This study established the varying impacts of different exercise parameters on the reduction of depression levels in hemodialysis patients and is anticipated to lay a theoretical reference for clinicians and nurses to devise tailored exercise strategies for interventions in patients with depression.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database, with registration number CRD42023434181.

Anticoagulation for people receiving long-term haemodialysis

BACKGROUND

Haemodialysis (HD) requires safe and effective anticoagulation to prevent clot formation within the extracorporeal circuit during dialysis treatments to enable adequate dialysis and minimise adverse events, including major bleeding. Low molecular weight heparin (LMWH) may provide a more predictable dose, reliable anticoagulant effects and be simpler to administer than unfractionated heparin (UFH) for HD anticoagulation, but may accumulate in the kidneys and lead to bleeding.

OBJECTIVES

To assess the efficacy and safety of anticoagulation strategies (including both heparin and non-heparin drugs) for long-term HD in people with kidney failure. Any intervention preventing clotting within the extracorporeal circuit without establishing anticoagulation within the patient, such as regional citrate, citrate enriched dialysate, heparin-coated dialysers, pre-dilution haemodiafiltration (HDF), and saline flushes were also included.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to November 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-randomised controlled studies (quasi-RCTs) evaluating anticoagulant agents administered during HD treatment in adults and children with kidney failure.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed the risk of bias using the Cochrane tool and extracted data. Treatment effects were estimated using random effects meta-analysis and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using the Grading of Recommendation, Assessment, Development and Evaluation approach (GRADE).

MAIN RESULTS

We included 113 studies randomising 4535 participants. The risk of bias in each study was adjudicated as high or unclear for most risk domains. Compared to UFH, LMWH had uncertain effects on extracorporeal circuit thrombosis (3 studies, 91 participants: RR 1.58, 95% CI 0.46 to 5.42; I2 = 8%; low certainty evidence), while major bleeding and minor bleeding were not adequately reported. Regional citrate anticoagulation may lower the risk of minor bleeding compared to UFH (2 studies, 82 participants: RR 0.34, 95% CI 0.14 to 0.85; I2 = 0%; low certainty evidence). No studies reported data comparing regional citrate to UFH on risks of extracorporeal circuit thrombosis and major bleeding. The effects of very LMWH, danaparoid, prostacyclin, direct thrombin inhibitors, factor XI inhibitors or heparin-grafted membranes were uncertain due to insufficient data. The effects of different LMWH, different doses of LMWH, and the administration of LMWH anticoagulants using inlet versus outlet bloodline or bolus versus infusion were uncertain. Evidence to compare citrate to another citrate or control was scant. The effects of UFH compared to no anticoagulant therapy or different doses of UFH were uncertain. Death, dialysis vascular access outcomes, blood transfusions, measures of anticoagulation effect, and costs of interventions were rarely reported. No studies evaluated the effects of treatment on non-fatal myocardial infarction, non-fatal stroke and hospital admissions. Adverse events were inconsistently and rarely reported.

AUTHORS' CONCLUSIONS

Anticoagulant strategies, including UFH and LMWH, have uncertain comparative risks on extracorporeal circuit thrombosis, while major bleeding and minor bleeding were not adequately reported. Regional citrate may decrease minor bleeding, but the effects on major bleeding and extracorporeal circuit thrombosis were not reported. Evidence supporting clinical decision-making for different forms of anticoagulant strategies for HD is of low and very low certainty, as available studies have not been designed to measure treatment effects on important clinical outcomes.

Lipid and Bone Effects of Heparin Use During Hemodialysis

Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly prescribed anticoagulants for chronic hemodialysis (HD). The dialysis population comprises a unique group that receives heparin three times per week for a long period, with potential long-term cumulative metabolic effects such as osteoporosis and worsening lipid profile. HD patients have approximately half the number of lipases as healthy individuals, and their lipid metabolism is limited because of this decrease as well as partially inhibited function. Administration of UFH or LMWHs for anticoagulation can lead to metabolic starvation despite high triglyceride levels at the end of HD. In vitro studies indicate that UFH and LMWHs inhibit osteoblasts and promote osteoclasts. In patients on HD, long-term use of UFH or LMWHs did not worsen chronic kidney disease-mineral bone disease. Further investigation is needed to elucidate the underlining mechanisms of UFH and LMWHs and their possible influences on maintenance HD patients.

Dialysis for older adults: why should the targets be different?

The number of patients aged > 75-years treated by dialysis continues to increase, particularly in developed countries. Haemodialysis is a well-established treatment with national and international clinical guidelines designed to provide patients with optimal treatment. However, these were developed when the dialysis population was younger, and less co-morbid. This change in patient demographics questions whether these guideline targets still apply to older patients. More patients now start dialysis with residual kidney function and could benefit from a less frequent dialysis schedule. Older patients have a lower thirst drive, so lower interdialytic gains, reduced appetite, muscle mass and physical activity would potentially allow starting dialysis with less frequent sessions a practical option. Similarly, patients with residual kidney function and lower metabolic activity may not need to meet current dialyser Kt/Vurea clearance targets to remain healthy. Instead, some elderly patients may be at risk of malnutrition and might need liberalisation of the low salt, potassium and phosphate dietary restrictions, or even additional supplements to ensure adequate protein intake. Although a fistula is the preferred vascular access, a forearm fistula may not be an option due to vascular disease, while a brachial fistula can potentially compromise cardiovascular reserve, so a dialysis catheter becomes the de facto access, especially in patients with limited life expectancy. Thus, clinical guideline targets designed for a younger less co-morbid dialysis population may not be equally applicable to the older patient initiating dialysis, and so a more individualised approach to dialysis prescription and vascular access is required.

Prosthetic brachial artery-external jugular vein arteriovenous grafts as a novel option for hemodialysis access: A case report

Following the exhaustion of all conventional hemodialysis access options in the upper extremities, a prosthetic arteriovenous loop was performed between the brachial artery (BA) and the external jugular vein (EJV) as a novel access option for hemodialysis in the present case report. During the procedure, a polytetrafluoroethylene graft was anastomosed to the BA and the EJV, and looped on the upper limb. The safety and reliability of BA-EJV access was evaluated by determining the complications, patency and intervention rates. The patient was then followed up for 20 months. The graft became thrombosed 20 months after the placement. There were no complications, such as infection, bleeding or aneurysmal lesions. Overall, the present study demonstrates that hemodialysis via BA-EJV access represents an unusual, yet effective and safe procedure, which may be conducted with acceptable complications and patency rates.

Anticoagulation practices for continuous renal replacement therapy: a survey of physicians from the United States

BACKGROUND

During continuous renal replacement therapy (CRRT), anticoagulants are recommended for patients at low risk of bleeding and not already receiving systemic anticoagulants. Current anticoagulants used in CRRT in the US are systemic heparins or regional citrate. To better understand use of anticoagulants for CRRT in the US, we surveyed nephrologists and critical care medicine (CCM) specialists.

METHODS

The survey contained 30 questions. Respondents were board certified and worked in intensive care units of academic medical centers or community hospitals.

RESULTS

150 physicians (70 nephrologists and 80 CCM) completed the survey. Mean number of CRRT machines in use increased ∼30% from the pre-pandemic era to 2022. Unfractionated heparin was the most used anticoagulant (43% of estimated patients) followed by citrate (28%). Respondents reported 29% of patients received no anticoagulant. Risk of hypocalcemia (52%) and citrate safety (42%) were the predominant reasons given for using no anticoagulant instead of citrate in heparin-intolerant patients. 84% said filter clogging was a problem when no anticoagulant was used, and almost 25% said increased transfusions were necessary. Respondents using heparin (n = 131) considered it inexpensive and easily obtainable, although of moderate safety, citing concerns of heparin-induced thrombocytopenia and bleeding. Anticoagulant citrate dextrose solution was the most used citrate. Respondents estimated that 37% of patients receiving citrate develop hypocalcemia and 17% citrate lock.

CONCLUSIONS

Given the increased use of CRRT and the lack of approved, safe, and effective anticoagulant choices for CRRT in the US, effective use of current and other anticoagulant options needs to be evaluated.

The Implementation of a Modified Fluid Assessment Tool to Improve the Clinical Assessment, Detection, and Management of Blood Pressure Control and Fluid Alterations Among Hemodialysis Patients

Background

Fluid overload is a common complication of the care of End-stage Renal Disease patients that may lead to prolonged hospitalization and mortality. This warrants an effective and systemic approach to early recognition and management to improve patient outcomes.

Aim

This study aims to evaluate the effect of a modified fluid assessment tool to improve accurate clinical assessments, detection, and management of blood pressure control and fluid alteration among hemodialysis patients.

Methods

In this retrospective study, data were collected from forty-three dialysis patients who were seen and followed up from a dialysis unit of an acute care hospital during 8 weeks of standard care. A modified assessment tool was used to systematically highlight the appropriateness of the patient set dry weight using intradialytic weight gain (IWDG) and patient blood pressure. Paired sample t-test and repeated measure ANOVA within-group analysis were applied to compare the mean difference score for IDWG and the mean arterial pressure within the study group, respectively.

Result

A total of 43 patients were enrolled (mean age, 59.07) (ranges 27-88 years) (SD - 14.30); 51.16% female; 79% Emirati Nationals, with Chronic Kidney Disease. A repeated measure ANOVA analysis showed a significant difference in the mean arterial pressure within the study group based on time, over six measurements (p = 0.001). However, the difference between the pre- and post-intra-dialytic weight gain mean scores yields insignificant results (p = 0.346).

Conclusion

The implementation of a modified assessment tool improved blood pressure control, increased staff and physician involvement in assessing patient dry weight facilitated through fluid status evaluation, methodical assessment of dry weight, and precise fluid removal calculation, enhancing overall blood pressure and fluid management in HD patients.

The trajectory of a range of commonly captured symptoms with standard care in people with kidney failure receiving haemodialysis: consideration for clinical trial design

BACKGROUND

Despite the recognized high symptom prevalence in haemodialysis population, how these symptoms change over time and its implications for clinical practice and research is poorly understood.

METHODS

Prevalent haemodialysis patients in the SHAREHD trial reported 17 POS-S Renal symptoms (none, mild, moderate, severe and overwhelming) at baseline, 6, 12 and 18 months. To assess the prevalence change at population level in people reporting moderate or worse symptoms at baseline, the absolute change in prevalence was estimated using multi-level mixed effects probit regression adjusting for age, sex, time on haemodialysis and Charlson Comorbidity Score. To assess changes at individual level, the proportion of people changing their symptom score every 6 months was estimated.

RESULTS

Five hundred fifty-two participants completed 1725 questionnaires at four timepoints. Across all 17 symptoms with moderate or worse symptom severity at baseline, the majority of the change in symptom prevalence at population level occurred in the 'severe' category. The absolute improvement in prevalence of the 'severe' category was ≤ 20% over 18 months in eleven of the seventeen symptoms despite a large degree of relatively balanced movement of individuals in and out of severe category every six months. Examples include depression, skin changes and drowsiness, which had larger proportion (75-80%) moving in and out of severe category each 6 months period but < 5% difference between movement in and out of severe category resulting in relatively static prevalence over time. Meanwhile, larger changes in prevalence of > 20% were observed in six symptoms, driven by a 9 to 18% difference between movement in and movement out of severe category. All symptoms had > 50% of people in severe group changing severity within 6 months.

CONCLUSIONS

Changes in the severity of existing symptoms under standard care were frequent, often occurring within six months. Certain symptoms exhibited clinically meaningful shifts at both the population and individual levels. This highlighted the need to consider improvements in symptom severity when determining sample size and statistical power for trials. By accounting for potential symptom improvements with routine care, researchers can design trials capable of robustly detecting genuine treatment effects, distinguishing them from spontaneous changes associated with standard haemodialysis.

Nephrology nurses' perspectives working with patients experiencing needle-related distress

BACKGROUND

A key skill of nephrology nursing is cannulation of patients receiving haemodialysis. Traumatic and unsuccessful cannulation experiences, particularly in the initial weeks of haemodialysis, may contribute to the onset of needle distress for patients.

OBJECTIVES

To identify the key knowledge, skills and attitudes of nephrology nurses working with haemodialysis patients and the competencies relevant to nephrology nursing working with patients with needle-related distress.

DESIGN

A qualitative study involving semistructured interviews. Interviews were audio-recorded, transcribed and deductive, and inductive thematic analysis applied.

PARTICIPANTS

Nephrology nurses (n = 17) were interviewed from a tertiary kidney service in South Australia. Nurses had varying roles and years of experience (range 1-30 years) working with dialysis patients within the service.

RESULTS

Two overarching themes, (1) Flexibility in Practice and Care and (2) Responsibility of Nephrology Nursing, were identified as relevant across all knowledge, skills and attitudes of nephrology nurses working with patients with needle-related distress. Thirty-six knowledge, skills and attitudes were identified; 12 related to knowledge, 14 related to skills and 10 were identified as attitudes and were summarised under seven broad competencies.

CONCLUSION

This study identifies potential knowledge, skills and attitudes and competencies required for nephrology nurses working with patients with needle-related distress. It highlights strategies that may prevent the onset and worsening of needle-related distress, as well as reduce it. It also brings to light that nurses desire additional education regarding strategies to improve the patient experience of cannulation and nurse confidence and skill in this area.

Does cooled dialysate still have a role in reducing intradialytic stress? Implications of the MyTEMP trial

PURPOSE OF REVIEW

There is an excess of cardiovascular morbidity and mortality in the maintenance haemodialysis population. Targeting traditional risk factors (e.g. hypercholesterolaemia) do not improve cardiovascular outcomes. Repeated myocardial stunning during haemodialysis is an important nontraditional risk, resulting in pathological cardiac remodelling and fibrosis. This review explores dialysate cooling as a management strategy to promote haemodynamic stability, reduce myocardial injury, and improve cardiovascular disease outcomes for individuals receiving maintenance haemodialysis.

RECENT FINDINGS

Observational data and small interventional studies demonstrate dialysate cooling has the potential to reduce end-organ damage and provide cardioprotection, renal protection and neuroprotection compared with standard care. These data are limited by the small sample sizes, short follow-up times and lack of long-term patient important outcomes. The MyTEMP study, a multicentre pragmatic randomized controlled trial, demonstrated cooled dialysate (0.5°C below body temperature) vs. standard care did not improve cardiovascular outcomes for prevalent haemodialysis patients.

SUMMARY

Dialysate cooling has been widely adopted into routine clinical practice; the MyTEMP study challenges the unit-level approach to implementing dialysate cooling. Due to methodological limitations, the absence of other important patient outcome measures, and lack of granularity of patient-level data, dialysate cooling should not be hastily removed from all dialysis care and warrants further research.

Pharmacological management of hypertension and outcome among patients on hemodialysis at Muhimbili National Hospital, Tanzania: a cross-sectional study

Introduction

hypertension is prevalent among patients attending hemodialysis. However, published information on hypertension management among patients on hemodialysis in African countries is scarce. This study assessed antihypertensive medication prescribing patterns and blood pressure control among patients with hypertension on hemodialysis in Tanzania.

Methods

an analytical cross-sectional study was conducted at Muhimbili National Hospital in Dar es Salaam from April to June 2022. The study population consisted of patients with hypertension undergoing hemodialysis. Data on demographic, clinical characteristics and the antihypertensive medications used by the patients was collected using a structured questionnaire. Analysis was performed using Statistical Package for the Social Sciences software version 26. Uncontrolled pre-dialysis blood pressure determinants were assessed using a modified Poisson regression model. A p-value < 0.05 was considered statistically significant.

Results

out of 314 participants, the majority (68.2%, n= 214) were male, and the median age was 52 (interquartile range: 42, 60) years. Only 16.9% (n= 53) of patients had their pre-dialysis blood pressure controlled. The most frequent antihypertensive medications prescribed were calcium channel blockers (73.2%, n= 230). Patients with less than three dialysis sessions were 20% more likely to have uncontrolled blood pressure than those with three sessions in a week (adjusted prevalence ratio = 1.2).

Conclusion

most patients on hemodialysis with hypertension had poor blood pressure control, according to the study. Patients with hypertension should be strongly encouraged to adhere to at least three hemodialysis treatments to achieve optimal blood pressure control.

Multicentre, observational, retrospective cohort of hyperkalaemia burden at haemodialysis facility-level in China: the Visualize-HD study protocol

OBJECTIVES

Hyperkalaemia is a potentially life-threatening disorder in patients undergoing haemodialysis (HD). Excess mortality and hospitalisation have been associated with hyperkalaemia (HK) after the long (2-day) interdialytic interval (LIDI) in patients on thrice a week HD compared with the short (1-day) interdialytic interval. Moreover, not much research has been conducted in China on the descriptive epidemiology and management of HK among different HD centres. The aim of this study is to address this evidence gap by investigating the risk factors associated with HK clinical burden at the HD facility level, current HD centres management patterns, serum potassium management patterns, as well as the risk factors associated with crude mortality in China.

DESIGN

Multicentre, observational, retrospective cohort study.

SETTING

This study plans to enrol 300 HD centres across China. Haemodialysis centres having ≥100 patients on maintenance HD within 3 years before study initiation, with participation willingness, routine blood collection post-LIDI and death records will be included.

PARTICIPANTS

Patients aged ≥18 years and on chronic HD for ≥3 months will be considered eligible. Summary data about serum potassium, characteristics of patients, facility practice patterns will be collected at HD facility level and death records will be at the patient level.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome will be to examine the association between suspected risk factors and HK prevalence at HD facility level. Suspected risk factors include dialysis prescriptions and serum potassium testing frequency, characteristics of patients and related medication usage. The secondary outcome will be to determine the HK prevalence, serum potassium management pattern and risk factors associated with crude mortality. The primary and secondary outcomes will be analysed using regression models. Exploratory outcomes will further investigate the risk factors associated with serum potassium ≥6.0 and ≥6.5 mmol/L.

CONCLUSION

The study is expected to provide insights to improve dialysis practice patterns and understand the clinical burden of HK.

ETHICS AND DISSEMINATION

This study protocol was reviewed and approved by the Institutional Review Boards and Ethics Committee of Peking University People's Hospital (Approval number: 2020PHB324-01). The results will be disseminated through national and international presentations and peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT05020717.

Microplastics and nanoplastics in haemodialysis waters: Emerging threats to be in our radar

Microplastics are present in the environment, in drinking water, in human blood and there is evidence of nanoplastics in tap water. The objective of this work was to analyze the possibility of hemodialysis patients being contaminated by micro and nanoplastics (MNPs) during dialysis treatment. The motivation for this investigation is the fact that hemodialysis patients use about 300-600 L of drinking water per week, which may be contaminated by MNPs. A literature review, a field investigation in a London hospital and an estimation of MNPs intake in patients were carried out. The results showed potential points of risk of contamination of patients by MNPs in hemodialysis. It was also estimated that for a filtration efficiency of 99 % for MNPs, the amount of microplastics that can penetrate the kidneys of patients is 0.0021-3768 particles/week. The assessment concludes that hemodialysis patients are at high risk of MNP contamination.

Surgical Referral for Hemodialysis Access Maintenance

Hemodialysis access is the lifeline for end-stage renal disease patients. However, dialysis access is associated with a host of complications, including thrombosis, recurrent stenosis, infection, aneurysmal changes and bleeding. Although endovascular therapy remains the first-line treatment owing to its less invasive nature, there are certain situations where surgical referral is recommended or even necessary. Regardless, management of dialysis access complications requires a multidisciplinary approach. Interventional radiologists should be familiar with the appropriate timing for surgical referral to better serve the complex patient population.

The NightLife study - the clinical and cost-effectiveness of thrice-weekly, extended, in-centre nocturnal haemodialysis versus daytime haemodialysis using a mixed methods approach: study protocol for a randomised controlled trial

BACKGROUND

In-centre nocturnal haemodialysis (INHD) offers extended-hours haemodialysis, 6 to 8 h thrice-weekly overnight, with the support of dialysis specialist nurses. There is increasing observational data demonstrating potential benefits of INHD on health-related quality of life (HRQoL). There is a lack of randomised controlled trial (RCT) data to confirm these benefits and assess safety.

METHODS

The NightLife study is a pragmatic, two-arm, multicentre RCT comparing the impact of 6 months INHD to conventional haemodialysis (thrice-weekly daytime in-centre haemodialysis, 3.5-5 h per session). The primary outcome is the total score from the Kidney Disease Quality of Life tool at 6 months. Secondary outcomes include sleep and cognitive function, measures of safety, adherence to dialysis and impact on clinical parameters. There is an embedded Process Evaluation to assess implementation, health economic modelling and a QuinteT Recruitment Intervention to understand factors that influence recruitment and retention. Adults (≥ 18 years old) who have been established on haemodialysis for > 3 months are eligible to participate.

DISCUSSION

There are 68,000 adults in the UK that need kidney replacement therapy (KRT), with in-centre haemodialysis the treatment modality for over a third of cases. HRQoL is an independent predictor of hospitalisation and mortality in individuals on maintenance dialysis. Haemodialysis is associated with poor HRQoL in comparison to the general population. INHD has the potential to improve HRQoL. Vigorous RCT evidence of effectiveness is lacking. The NightLife study is an essential step in the understanding of dialysis therapies and will guide patient-centred decisions regarding KRT in the future.

TRIAL REGISTRATION

Trial registration number: ISRCTN87042063. Registered: 14/07/2020.

Effects of Different Exercises on Physical Function, Dialysis Adequacy, and Health-Related Quality of Life in Maintenance Hemodialysis Patients: A Systematic Review and Network Meta-Analysis

BACKGROUND

Clinical guidelines recommend exercise training for patients undergoing maintenance hemodialysis (MHD). However, the effectiveness of different types of exercise remains uncertain.

OBJECTIVES

The aims of the study were to compare and rank the effect of different types of exercise on walking capacity, cardiorespiratory fitness, dialysis adequacy, and health-related quality of life (HRQOL) in patients undergoing MHD.

METHODS

Eight databases (four English and four Chinese) were searched from inception to January 1, 2022. Randomized controlled trials evaluating the efficacy of different exercises for patients undergoing MHD were included. Two independent reviewers screened the literature, extracted data, assessed the risk of bias, and evaluated the certainty of evidence. A frequentist random-effect network meta-analysis was conducted.

RESULTS

Ninety trials with 4,084 participants comparing 15 types of exercise were included, reporting on the six-minute walking test (45 trials), peak oxygen uptake (22 trials), dialysis adequacy (30 trials), and HRQOL (23 trials). Network meta-analysis showed that the most effective intervention for walking capacity was intradialytic aerobic exercise combined with blood flow restriction with a mean difference and 95% confidence interval of 97.35 (11.89-182.81), for peak oxygen uptake it was non-intradialytic combined aerobic and resistance exercise with a value of 4.35 (2.25-6.44), for dialysis adequacy it was intradialytic combined aerobic and resistance exercise with a value of 0.17 (0.06-0.28), for the physical component summary of HRQOL it was intradialytic aerobic exercise with a value of 4.93 (2.31-7.54), and for the mental component summary of HRQOL it was non-intradialytic combined aerobic and resistance exercise with a value of 6.36 (0.45-12.27). Ultimately, intradialytic combined aerobic and resistance exercise could improve all the above outcomes compared to usual care.

CONCLUSIONS

This study concluded that intradialytic combined aerobic and resistance exercise is optimal for MHD patients due to its significant positive effects on multiple outcomes. Walking capacity can be further enhanced by combining blood flow restriction with exercise. For improving dialysis adequacy, intradialytic exercise proves to be more effective than non-intradialytic exercise. Further well-designed clinical trials are needed to investigate the effects of exercise with varying durations, intensities, and frequencies.

Prevention of Intradialytic Hypotension in Hemodialysis Patients: Current Challenges and Future Prospects

Intradialytic hypotension, defined as rapid decrease in systolic blood pressure of greater than or equal to 20 mmHg or in mean arterial pressure of greater than or equal to 10 mmHg that results in end-organ ischemia and requires countermeasures such as ultrafiltration reduction or saline infusion to increase blood pressure to improve patient's symptoms, is a known complication of hemodialysis and is associated with several potential adverse outcomes. Its pathogenesis is complex and involves both patient-related factors such as age and comorbidities, as well as factors related to the dialysis prescription itself. Key factors include the need for volume removal during hemodialysis and a suboptimal vascular response which compromises the ability to compensate for acute intravascular volume loss. Inadequate vascular refill, incorrect assessment or unaccounted changes of target weight, acute illnesses and medication interference are further potential contributors. Intradialytic hypotension can lead to compromised tissue perfusion and end-organ damage, both acutely and over time, resulting in repetitive injuries. To address these problems, a careful assessment of subjective symptoms, minimizing interdialytic weight gains, individualizing dialysis prescription and adjusting the dialysis procedure based on patients' risk factors can mitigate negative outcomes.

Short-term outcomes of colorectal cancer surgery in patients with dialysis: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to evaluate the effect of dialysis-dependent chronic kidney disease (CKD) on postoperative complications in colorectal cancer surgery.

METHODS

In April 2023, we systematically searched PubMed, the Cochrane library, and Ovid for relevant studies on short-term outcomes of colorectal cancer surgery in patients with dialysis and analyzed the findings from these studies for meta-analysis.

RESULTS

Our systematic and meta-analysis review identified seven studies involving 50713 patients. We showed that the dialysis group had higher rates of mortality (OR = 4.12, 95%CI: 2.75-6.20, P < 0.001), cardiac complications (OR = 2.45, 95%CI: 1.88-3.21, P < 0.001), and pneumonia (OR = 2.68, 95%CI: 1.83-3.93, P < 0.001). On the other hand, there were no differences in superficial/deep surgical site infection (SSI) (odds ratio [OR] = 1.17, 95%CI: 0.90-1.53, P = 0.230) and organ/space SSI (OR = 1.35, 95%CI: 1.00-1.82, P = 0.053) between the dialysis group and non-dialysis group.

CONCLUSION

Our meta-analysis showed that dialysis-dependent CKD was associated with higher rates of mortality, cardiac complications, and pneumonia after colorectal cancer surgery. However, the limitations of this meta-analysis should be taken into consideration when interpreting the results.

Branched-chain ketoacid co-ingestion with protein lowers amino acid oxidation during hemodialysis: A randomized controlled cross-over trial

BACKGROUND & AIMS

Hemodialysis removes amino acids from the circulation, thereby stimulating muscle proteolysis. Protein ingestion during hemodialysis can compensate for amino acid removal but may also increase uremic toxin production. Branched-chain ketoacid (BCKA) co-ingestion may provide an additional anabolic stimulus without adding to uremic toxin accumulation. In the present study we assessed the impact of BCKA co-ingestion with protein on forearm amino acid balance and amino acid oxidation during hemodialysis.

METHODS

Nine patients (age: 73 ± 10 y) on chronic hemodialysis participated in this crossover trial. During two 4-h hemodialysis sessions, patients ingested 18 g protein with (PRO + BCKA) or without (PRO) 9 g BCKAs in a randomized order. Test beverages were labeled with L-[ring-¹³C₆]-phenylalanine and provided throughout the last 3 h of hemodialysis as 18 equal sips consumed with 10-min intervals. Arterial and venous plasma as well as breath samples were collected frequently throughout hemodialysis.

RESULTS

Arterial plasma total amino acid (TAA) concentrations during PRO and PRO + BCKA treatments were significantly lower after 1 h of hemodialysis (2.6 ± 0.3 and 2.6 ± 0.3 mmol/L, respectively) when compared to pre-hemodialysis concentrations (4.2 ± 1.0 and 4.0 ± 0.5 mmol/L, respectively; time effect: P < 0.001). Arterial plasma TAA concentrations increased throughout test beverage ingestion (time effect: P = 0.027) without differences between treatments (time∗treatment: P = 0.62). Forearm arteriovenous TAA balance during test beverage ingestion did not differ between timepoints (time effect: P = 0.31) or treatments (time∗treatment: P = 0.34). Whole-body phenylalanine oxidation was 33 ± 16% lower during PRO + BCKA when compared to PRO treatments (P < 0.001).

CONCLUSIONS

BCKA co-ingestion with protein during hemodialysis does not improve forearm net protein balance but lowers amino acid oxidation.

Anti-Xa level monitoring of low-molecular-weight heparin during intermittent venovenous hemofiltration

Low-molecular-weight heparin (LMWH) is an anticoagulant used to prevent clotting during blood purification treatments. This study aimed to evaluate the clinical use of the anti-factor Xa level (anti-Xa) for monitoring LMWH anticoagulant levels during intermittent venovenous hemofiltration (IVVHF). This prospective observational study enrolled patients who required IVVHF for renal failure in Beijing Hospital between May 2019 and February 2021. The LMWH anticoagulation was assessed by the coagulation grade of the filter and line. One hundred and ten participants were included. There were 90 patients with a filter and line coagulation grade of ≤ 1 and 20 patients with grade > 1. The anti-Xa level of 0.2 IU/mL was a critical value. The multivariable logistic regression analysis showed that anti-Xa level > 0.2 IU/mL (odd ratio [OR] = 2.263; 95% CI: 1.290-4.871, P = 0.034) and cardiovascular disease (OR = 10.028; 95% CI: 1.204-83.488; P = 0.033) were independently associated with the coagulation grade of the filter and line. Anti-Xa level could monitor LMWH anticoagulation during IVVHF.

Randomized Trial on the Effects of Dialysate Potassium Concentration on Intradialytic Hypertension

Introduction

Intradialytic hypertension is not an uncommon condition during chronic hemodialysis. It is associated with unfavorable cardiovascular outcomes, including hospitalization and mortality. Several small studies have demonstrated the contradictory effects of different dialysate potassium concentrations on intradialytic blood pressure. This study is a randomized crossover trial aiming to evaluate the effects of different dialysate potassium concentrations on intradialytic hypertension.

Methods

A 24-week, 2-treatment, 4-sequence, multicenter, double-blinded, randomized, crossover study was conducted at Maharaj Nakorn Chiang Mai Hospital and Lampang Hospital in Thailand among stable patients receiving chronic hemodialysis who experienced intradialytic hypertension >30% of their sessions over the past 3 months. Each participant was randomly assigned to 1 of 4 treatment sequences. During each intervention period, patients were dialyzed with dialysate potassium of either 2 mmol/l (D-K2) or 3 mmol/l (D-K3) for 4 weeks according to their preassigned sequence, separated by a 2-week washout period. The primary outcome was the incidence of intradialytic hypertension.

Results

Forty eligible patients were recruited. The mean age was 61.4 ± 14.2 years and the mean systolic blood pressure (SBP) was 146.6 ± 11.2 mm Hg. Of the 40 patients, 95.5% had hypertension and their average number of antihypertensive drugs was 2.8 ± 1.9. A total of 1380 dialysis sessions were included in the analysis (695 sessions for D-K2 and 685 sessions for D-K3). The incidence of intradialytic hypertension was not significantly different between different dialysate potassium concentrations (D-K2 54.7% vs. D-K3 53.1%, P = 0.788). The changes in SBP, diastolic blood pressure (DBP), and mean arterial pressure (MAP) were not different between the 2 dialysate potassium groups.

Conclusion

Dialysate potassium concentration of 2 or 3 mmol/l did not affect the incidence of intradialytic hypertension in patients receiving chronic hemodialysis who frequently developed intradialytic hypertension.

The effect of a novel, digital physical activity and emotional well-being intervention on health-related quality of life in people with chronic kidney disease: trial design and baseline data from a multicentre prospective, wait-list randomised controlled trial (kidney BEAM)

BACKGROUND

Physical activity and emotional self-management has the potential to enhance health-related quality of life (HRQoL), but few people with chronic kidney disease (CKD) have access to resources and support. The Kidney BEAM trial aims to evaluate whether an evidence-based physical activity and emotional wellbeing self-management programme (Kidney BEAM) leads to improvements in HRQoL in people with CKD.

METHODS

This was a prospective, multicentre, randomised waitlist-controlled trial, with health economic analysis and nested qualitative studies. In total, three hundred and four adults with established CKD were recruited from 11 UK kidney units. Participants were randomly assigned to the intervention (Kidney BEAM) or a wait list control group (1:1). The primary outcome was the between-group difference in Kidney Disease Quality of Life (KDQoL) mental component summary score (MCS) at 12 weeks. Secondary outcomes included the KDQoL physical component summary score, kidney-specific scores, fatigue, life participation, depression and anxiety, physical function, clinical chemistry, healthcare utilisation and harms. All outcomes were measured at baseline and 12 weeks, with long-term HRQoL and adherence also collected at six months follow-up. A nested qualitative study explored experience and impact of using Kidney BEAM.

RESULTS

340 participants were randomised to Kidney BEAM (n = 173) and waiting list (n = 167) groups. There were 96 (55%) and 89 (53%) males in the intervention and waiting list groups respectively, and the mean (SD) age was 53 (14) years in both groups. Ethnicity, body mass, CKD stage, and history of diabetes and hypertension were comparable across groups. The mean (SD) of the MCS was similar in both groups, 44.7 (10.8) and 45.9 (10.6) in the intervention and waiting list groups respectively.

CONCLUSION

Results from this trial will establish whether the Kidney BEAM self management programme is a cost-effective method of enhancing mental and physical wellbeing of people with CKD.

TRIAL REGISTRATION

NCT04872933. Registered 5th May 2021.

Why is Intradialytic Hypotension the Commonest Complication of Outpatient Dialysis Treatments?

Intradialytic hypotension (IDH) is the most frequent complication of hemodialysis (HD) treatments with a frequency of 10% to 12% for patients with chronic kidney disease attending for outpatient treatments and is associated with both temporary ischemic stress to vital organs, including the heart and brain, and increased patient mortality. Although there have been many different definitions of IDH over the years, an absolute nadir systolic blood pressure (SBP) has the strongest association with patient outcomes. The unifying pathophysiology is one of reduced effective blood volume, resulting in lower plasma tonicity, and if this cannot be adequately compensated for by activation of neurohumeral systems, then arteriolar tone and blood pressure fall. The risk factors for developing IDH are numerous, ranging from patient-related factors, including age and comorbidity with reduced cardiac reserve, to patient compliance with dietary and lifestyle advice, to reactions with the extracorporeal circuit and medications, choice of dialysate composition and temperature, setting of postdialysis target weight, ultrafiltration rate, and profiling. Advances in dialysis machine technology by providing real time estimates of the effective circulating volume and adjusting dialysate composition to maintain vascular tonicity are being developed, but currently require more sophisticated biofeedback loops to be clinically effective in preventing IDH. While awaiting advances in artificial intelligence, the clinician continues to rely on patient education to limit interdialytic weight gains, frequent assessment of the postdialysis target weight, adjusting dialysate composition and temperature, introducing convective therapies to increase thermal losses, and altering dialysis session duration and frequency to reduce ultrafiltration rate requirements.

Intradialytic Protein Ingestion and Exercise do Not Compromise Uremic Toxin Removal Throughout Hemodialysis

OBJECTIVE

Dietary protein and physical activity interventions are increasingly implemented during hemodialysis to support muscle maintenance in patients with end-stage renal disease (ESRD). Although muscle maintenance is important, adequate removal of uremic toxins throughout hemodialysis is the primary concern for patients. It remains to be established whether intradialytic protein ingestion and/or exercise modulate uremic toxin removal during hemodialysis.

METHODS

We recruited 10 patients with ESRD (age: 65 ± 16 y, BMI: 24.2 ± 4.8 kg/m²) on chronic hemodialysis treatment to participate in this randomized cross-over trial. During hemodialysis, patients were assigned to ingest 40 g protein or a nonprotein placebo both at rest (protein [PRO] and placebo [PLA], respectively) and following 30 min of exercise (PRO + exercise [EX] and PLA + EX, respectively). Blood and spent dialysate samples were collected throughout hemodialysis to assess reduction ratios and removal of urea, creatinine, phosphate, cystatin C, and indoxyl sulfate.

RESULTS

The reduction ratios of urea and indoxyl sulfate were higher during PLA (76 ± 6% and 46 ± 9%, respectively) and PLA + EX interventions (77 ± 5% and 45 ± 10%, respectively) when compared to PRO (72 ± 4% and 40 ± 8%, respectively) and PRO + EX interventions (73 ± 4% and 43 ± 7%, respectively; protein effect: P = .001 and P = .023, respectively; exercise effect: P = .25 and P = .52, respectively). Nonetheless, protein ingestion resulted in greater urea removal (P = .046) during hemodialysis. Reduction ratios and removal of creatinine, phosphate, and cystatin C during hemodialysis did not differ following intradialytic protein ingestion or exercise (protein effect: P > .05; exercise effect: P>.05). Urea, creatinine, and phosphate removal were greater throughout the period with intradialytic exercise during PLA + EX and PRO + EX interventions when compared to the same period during PLA and PRO interventions (exercise effect: P = .034, P = .039, and P = .022, respectively).

CONCLUSION

The removal of uremic toxins is not compromised by protein feeding and/or exercise implementation during hemodialysis in patients with ESRD.

Feasibility of randomized controlled trials and long-term implementation of interventions: Insights from a qualitative process evaluation of the PEDAL trial

Introduction

A multi-site randomized controlled trial was carried out between 2015 and 2019 to evaluate the impacts on quality of life of an intradialytic exercise programme for people living with chronic kidney disease. This included a qualitative process evaluation which gave valuable insights in relation to feasibility of the trial and of the intervention in the long-term. These can inform future clinical Trial design and evaluation studies.

Methods

A constructivist phenomenological approach underpinned face-to-face, semi-structured interviews. Purposive recruitment ensured inclusion of participants in different arms of the PEDAL Trial, providers with different roles and trial team members from seven Renal Units in five study regions. Following ethical review, those willing took part in one interview in the Renal Unit. Audio-recorded interviews were transcribed (intelligent verbatim) and inductively thematically analyzed.

Results

Participants (n = 65) (Intervention arm: 26% completed; 13% who did not; Usual care arm: 13%; 46% women; 54% men; mean age 60 year) and providers (n = 39) were interviewed (23% PEDAL Trial team members). Three themes emerged: (1) Implementing the Intervention; (2) Implementing the trial; and (3) Engagement of the clinical team. Explanatory theory named "the Ideal Scenario" was developed, illustrating complex interactions between different aspects of intervention and trial implementation with the clinical context. This describes characteristics likely to optimize trial feasibility and intervention sustainability in the long-term. Key aspects of this relate to careful integration of the trial within the clinical context to optimize promotion of the trial in the short-term and engagement and ownership in the long-term. Strong leadership in both the clinical and trial teams is crucial to ensure a proactive and empowering culture.

Conclusion

Novel explanatory theory is proposed with relevance for Implementation Science. The "Ideal Scenario" is provided to guide trialists in pre-emptive and ongoing risk analysis relating to trial feasibility and long-term intervention implementation. Alternative study designs should be explored to minimize the research-to-practice gap and optimize the likelihood of informative findings and long-term implementation. These might include Realist Randomized Controlled Trials and Hybrid Effectiveness-Implementation studies.

The Effect of Aromatherapy on Hemodialysis-Related Nausea: A Case Report

BACKGROUND: After hemodialysis, complications may occur and one of them that problematic is hemodialysis-related nausea. Information is still unclear about aromatherapy concerning nausea-related to hemodialysis. This study aimed to describe the effect of aromatherapy on nausea after hemodialysis procedures. CASE PRESENTATION: A 51-year-old female, undergoing routine hemodialysis, experienced severe hemodialysis-related nausea. Her nausea occurred a day after dialysis and existed for 3–4 days and this repeated as a cycle that affected her appetite, food intake, and general condition. The daily measurements of nausea used the visual analog scale and the nausea severity scale before and after the intervention. In addition, a manual book with a packet containing nausea education, protocol of intervention, and monitoring sheets, was provided. For two weeks, the application of two drops of lavender aromatherapy was given on a humid cotton swab and inhaled for 5 min. In addition, education explained oral hygiene using warm water when waking up in the morning and before eating food. There was a decrease in the intensity of nausea from severe to none based on daily measurements and from severe nausea (score: 21) to moderate nausea (score: 10) after the 2-weeks intervention. Thus, the patient could enjoy eating without any uncomfortable feeling of nausea. CONCLUSION: Lavender aromatherapy was demonstrated as a complementary therapy in overcoming nausea after dialysis among CKD patients. This report could provide a novel therapeutic modality for hemodialysis patients suffering hemodialysis-related nausea.

The effect of changing dialysate bicarbonate concentration on serum bicarbonate, body weight and normalized nitrogen appearance rate

INTRODUCTION

Most hemodialysis machines deliver a fixed bicarbonate concentration. Higher concentrations may improve acidosis, but risk post-hemodialysis alkalosis, whereas lower concentrations potentially increase acidosis but reduce alkalosis. We reviewed the effects of lowering dialysate bicarbonate.

METHODS

We reviewed peri-dialysis chemistries in patients switching to a lower bicarbonate dialysate at 4 time points over 19 months.

RESULTS

We studied 126 patients, mean age 63.7 ± 16.3 years, 57.9% males. Post-hemodialysis alkalosis fell from 1.6 to 0.3% sessions, but pre-hemodialysis acidosis increased from 11.9 to 23.8% sessions (p = 0.005) reducing dialysate bicarbonate from 32 to 28 mmol/L. After 3 months, pre-hemodialysis serum bicarbonate fell (21.1 ± 2.3 to 19.8 ± 2.2 mmol/L), and post-hemodialysis (24.9 ± 2.1 to 22.5 ± 2.0 mmol/L, p < 0.001) with a fall in pre-hemodialysis weight from 74.6 ± 20.7 to 71.7 ± 18.2 kg, normalized protein nitrogen accumulation rate 0.8 ± 0.28 to 0.77 ± 0.2 g/kg/day, p < 0.05, and serum albumin 39.7 ± 4.2 to 37.7 ± 4.9 g/L, p < 0.001. Thereafter, apart from pre- and post-hemodialysis serum bicarbonate, weight and normalized protein nitrogen accumulation stabilized, although albumin remained lower (37.6 ± 4.0 g/L, p < 0.001). On multivariate logistic analysis, serum bicarbonate increased more with lower pre-hemodialysis bicarbonate standardized coefficient β 0.5 (95% confidence interval -0.6 to -0.42), increased normalized protein nitrogen accumulation β 0.2 (0.96 to 2.38), p < 0.001, and session time β 0.09, (0.47 to 5.98), p < 0.022, and less with lower dialysate bicarbonate 0.0-0.23 (-1.54 to -0.74), p < 0.001.

CONCLUSION

Increases in SE-Bic with hemodialysis, depend on the bicarbonate gradient, session time and nPNA. Lower D-Bic reduces post-hemodialysis alkalosis but increases pre-hemodialysis acidosis and may initially have adverse effects on weight and normalized protein nitrogen accumulation.

The effect of local cold application on intradialytic cramp: A quasi-experimental study

Aims:

An intradialytic cramp, which frequently occurs in hemodialysis patients, is a disturbing condition. This study was conducted to evaluate the effect of local cold applications on the severity and duration of intradialytic cramps in patients with chronic kidney disease.

Materials and Methods:

This quasi-experimental study sample comprised of 74 patients who were aged >18 years, conscious, and reported experiencing intradialytic cramps in a dialysis center. In this study, the application group had the local cold treatment as well as the treatment recommended by the physician whereas the control group was only given the treatment recommended by the physician. The cramp severity was assessed using a visual analog scale as soon as the cramp started (T1) and 10 min after the onset of the cramp (T2). The cramp duration was determined by a chronometer. The Independent Sample T-test, One-Way ANOVA test, Paired Samples T-test and the Two-Way ANOVA test were used to analyze the data.

Results:

In the study, the duration of the cramp (sd) was 9.49 (0.86) minutes in the application group and 7.51 (0.69) minutes in the control group ( t = 1791, p = 0.078). It was determined that the pain severity scores of the application and control group patients were significantly decreased at the T2 time point compared to T1 ( p = 0.001), and the effect of the group and evaluation time points on the cramp severity score was not statistically different ( p = 0.548).

Conclusion:

In this study, the mean duration of the intradialytic cramp was below 10 min for both groups. The local cold application had no effect on cramp severity or duration.

Cardiovascular Effects of Home Dialysis Therapies: A Scientific Statement From the American Heart Association

Cardiovascular disease is the leading cause of morbidity and mortality in patients with end-stage kidney disease. Currently, thrice-weekly in-center hemodialysis for 3 to 5 hours per session is the most common therapy worldwide for patients with treated kidney failure. Outcomes with thrice-weekly in-center hemodialysis are poor. Emerging evidence supports the overarching hypothesis that a more physiological approach to administering dialysis therapy, including in the home through home hemodialysis or peritoneal dialysis, may lead to improvement in several cardiovascular risk factors and cardiovascular outcomes compared with thrice-weekly in-center hemodialysis. The Advancing American Kidney Health Initiative, which has a goal of increasing the use of home dialysis, is aligned with the American Heart Association's 2024 mission to champion a full and healthy life and health equity. We conclude that incorporation of interdisciplinary care models to increase the use of home dialysis therapies in an equitable manner will contribute to the ultimate goal of improving outcomes for patients with kidney failure and cardiovascular disease.

Twice versus thrice weekly hemodialysis: A systematic review

INTRODUCTION

Thrice weekly hemodialysis (HD) is currently the norm in high income countries but there is mounting interest in twice weekly HD in certain settings. We performed this systematic review to summarize the available evidence comparing twice to thrice weekly HD.

METHODS

A systematic literature search was performed in Ovid MEDLINE, Ovid Embase, and the Cochrane Central Register of Controlled Trials to identify cohort and randomized controlled trials evaluating outcomes of twice versus thrice weekly HD. The bibliographies of identified studies were hand searched to find any additional studies. Risk of bias was assessed using the Newcastle-Ottawa scale for observational studies.

FINDINGS

No randomized controlled trials and 21 cohort studies were identified. Overall study quality was modest with high risk of selection bias and inadequate controlling for confounders. The most commonly evaluated outcome measures were survival and residual kidney function. No studies assessed quality of life. Study results were variable and there was no clear signal for overwhelming risk or benefit of twice versus thrice weekly HD with the exception of residual kidney function which consistently showed slower decline in the twice weekly group.

DISCUSSION

There is a paucity of high quality data comparing the risks and benefits of twice vs thrice weekly HD. Randomized controlled trial evidence is required to inform clinicians and HD prescription guidelines.

Bioimpedance indices of fluid overload and cardiorenal outcomes in heart failure and chronic kidney disease: a systematic review

BACKGROUND

Bioimpedance-based estimates of fluid overload have been widely studied and systematically reviewed in dialysis populations, but data from heart failure or non-dialysis chronic kidney disease (CKD) populations have not.

METHODS AND RESULTS

We conducted a systematic review of studies using whole-body bioimpedance from heart failure and non-dialysis CKD populations which reported associations with mortality, cardiovascular outcomes and/or CKD progression. We searched MEDLINE, Embase databases and the Cochrane CENTRAL registry from inception to 14^th March 2022. Thirty one eligible studies were identified: 20 heart failure and 11 CKD cohorts, with 2 studies including over 1000 participants. A wide range of different bioimpedance methods were used across the studies (heart failure: 8 parameters; CKD: 6). Studies generally reported positive associations, but between-study differences in bioimpedance methods, fluid overload exposure definitions, and modelling approaches precluded meta-analysis. The largest identified study was in non-dialysis CKD (Chronic Renal Insufficiency Cohort, 3751 participants) which reported adjusted hazard ratios (95% confidence intervals) for phase angle <5.59 versus ≥6.4 of 2.02 (1.67-2.43) for all-cause mortality; 1.80 (1.46-2.23) for heart failure events; and 1.78 (1.56-2.04) for CKD progression.

CONCLUSIONS

Bioimpedance indices of fluid overload are associated with risk of important cardiorenal outcomes in heart failure and CKD. Facilitation of more widespread use of bioimpedance needs consensus on the optimum device, standardized analytical methods, and larger studies including more detailed characterization of cardiac and renal phenotypes.

Hypoxia during maintenance hemodialysis-the critical role of pH

Background

The impact and management of subclinical hypoxia during hemodialysis is a significant medical challenge. As key determinants of O₂ availability and delivery, proposed mechanisms contributing to hypoxia include ischemia, alkalemia and pulmonary leukocyte sequestration. However, no study has comprehensively investigated and compared these interrelated mechanisms throughout a typical hemodialysis treatment week. This study aimed to comprehensively assess the physiological mechanisms that contribute to hypoxia during hemodialysis.

Methods

In 76 patients, we measured arterial blood gases and pH at four time-points during hemodialysis (start, 15 min, 60 min, end) over the course of a standard treatment week. For the mid-week hemodialysis session, we additionally measured central hemodynamics (non-invasive cardiac output monitoring) and white blood cell count.

Results

Linear regression modelling identified changes in pH, but not central hemodynamics or white blood cell count, to be predictive of changes in PaO₂ throughout hemodialysis (e.g. at 60 min, β standardized coefficient pH = 0.45, model R² = 0.25, P < .001). Alkalemia, hypokalemia, decreased calcium and increased hemoglobin-O₂ affinity (leftward shift in the oxyhemoglobin dissociation curve) were evident at the end of hemodialysis. pH and hemoglobin-O₂ affinity at the start of hemodialysis increased incrementally over the course of a standard treatment week.

Conclusion

These data highlight the important role of pH in regulating O₂ availability and delivery during hemodialysis. Findings support routine pH monitoring and personalized dialysate bicarbonate prescription to mitigate the significant risk of alkalemia and subclinical hypoxia.

Water-Soluble Vitamins and Trace Elements Losses during On-Line Hemodiafiltration

Maintenance hemodialysis induces water-soluble vitamins and trace elements losses, which is why recommendations regarding potential supplementation were provided, but mainly based on conventional hemodialysis. This study′s aim was to measure the water–soluble vitamins and trace element losses during one on-line post-dilution hemodiafiltration (HDF) session. Thirty-nine patients under maintenance HDF were enrolled. We used the Theraflux^® sampler (Theradial Corp., Orvault, France) to analyze the full session dialysate mass transfer. Blood and dialysate samples were collected before and after one HDF session to measure B1, B2, B6, B9, B12, C vitamins, zinc, and selenium concentrations. Values significantly decreased for B1 (20.2%), B2 (13%), B6 (25.4%), B9 (32.6%), C (66.6%) and selenium (6.7%). No significant differences were found for vitamin B12 and zinc. The dialysate losses per session were 1.12 ± 0.88 mg for vitamin B1, 0.28 ± 0.30 mg for B2, 0.33 ± 0.09 mg for B6, 0.3 ± 0.18 mg for B9, 147.5 ± 145.50 mg for C and 25.75 ± 6.91 mg for zinc. Vitamin B12 and selenium were under detection values. In conclusion, during a standard 4hr-HDF session, we found important losses for vitamin B1, B6, B9, C and zinc, suggesting the need for regular monitoring of plasma levels and systematic supplementation of these compounds.

Executive summary of the Korean Society of Nephrology 2021 clinical practice guideline for optimal hemodialysis treatment

The Korean Society of Nephrology (KSN) has published a clinical practice guideline (CPG) document for maintenance hemodialysis (HD). The document, 2021 Clinical Practice Guideline on Optimal HD Treatment, is based on an extensive evidence-oriented review of the benefits of preparation, initiation, and maintenance therapy for HD, with the participation of representative experts from the KSN under the methodologists' support for guideline development. It was intended to help clinicians participating in HD treatment make safer and more effective clinical decisions by providing user-friendly guidelines. We hope that this CPG will be meaningful as a recommendation in practice, but not on a regulatory rule basis, as different approaches and treatments may be used by health care providers depending on the individual patient's condition. This CPG consists of eight sections and 15 key questions. Each begins with statements that are graded by the strength of recommendations and quality of the evidence. Each statement is followed by a summary of the evidence supporting the recommendations. There are also a link to full-text documents and lists of the most important reports so that the readers can read further (most of this is available online).

Global Policy Barriers and Enablers to Exercise and Physical Activity in Kidney Care

OBJECTIVE

Impairment in physical function and physical performance leads to decreased independence and health-related quality of life in people living with chronic kidney disease and end-stage kidney disease. Physical activity and exercise in kidney care are not priorities in policy development. We aimed to identify global policy-related enablers, barriers, and strategies to increase exercise participation and physical activity behavior for people living with kidney disease.

DESIGN AND METHODS

Guided by the Behavior Change Wheel theoretical framework, 50 global renal exercise experts developed policy barriers and enablers to exercise program implementation and physical activity promotion in kidney care. The consensus process consisted of developing themes from renal experts from North America, South America, Continental Europe, United Kingdom, Asia, and Oceania. Strategies to address enablers and barriers were identified by the group, and consensus was achieved.

RESULTS

We found that policies addressing funding, service provision, legislation, regulations, guidelines, the environment, communication, and marketing are required to support people with kidney disease to be physically active, participate in exercise, and improve health-related quality of life. We provide a global perspective and highlight Japanese, Canadian, and other regional examples where policies have been developed to increase renal physical activity and rehabilitation. We present recommendations targeting multiple stakeholders including nephrologists, nurses, allied health clinicians, organizations providing renal care and education, and renal program funders.

CONCLUSIONS

We strongly recommend the nephrology community and people living with kidney disease take action to change policy now, rather than idly waiting for indisputable clinical trial evidence that increasing physical activity, strength, fitness, and function improves the lives of people living with kidney disease.

Patient Preferences for Longer or More Frequent In-Center Hemodialysis Regimens: A Multicenter Discrete Choice Study

RATIONALE & OBJECTIVE

Longer and more frequent hemodialysis sessions are associated with both benefits and harms. However, their relative importance to patients and how they influence acceptability for patients have not been quantified.

STUDY DESIGN

Discrete-choice experiment in which a scenario followed by 12 treatment choice sets were presented to patients in conjunction with varying information about the clinical impact of the treatments offered.

SETTING & PARTICIPANTS

Patients with kidney failure treated with maintenance dialysis for≥1 year in 5 UK kidney centers.

PREDICTORS

Length and frequency of hemodialysis sessions and their prior reported associations with survival, quality of life, need for fluid restriction, hospitalization, and vascular access complications.

OUTCOME

Selection of longer (4.5 hours) or more frequent (4 sessions per week) hemodialysis regimens versus remaining on 3 sessions per week with session lengths of 4 hours.

ANALYTICAL APPROACH

Multinomial mixed effects logistic regression estimating the relative influence of different levels of the predictors on the selection of longer and more frequent dialysis, controlling for patient demographic characteristics.

RESULTS

Among 183 prevalent in-center hemodialysis patients (mean age of 63.7 years, mean dialysis vintage of 4.7 years), 38.3% (70 of 183) always chose to remain on regimens of 3 sessions per week with session duration of 4 hours. Depicted associations of increasing survival and quality of life, reduced need for fluid restriction, and avoiding additional access complications were all significantly associated with choosing longer or more frequent treatment regimens. Younger age, fatigue, previous experience of vascular access complications, absence of heart failure, and shorter travel time to dialysis centers were associated with preference for 4 sessions per week. Patients expressed willingness to trade up to 2 years of life to avoid regimens of 4 sessions per week or access complications. After applying estimated treatment benefits and harms from existing literature, the fully adjusted model revealed that 27.1% would choose longer regimens delivered 3 times per week and 34.3% would choose 4 hours 4 times per week. Analogous estimates for younger fatigued patients living near their unit were 23.5% and 62.5%, respectively.

LIMITATIONS

Estimates were based on stated preferences rather than observed behaviors. Predicted acceptance of regimens was derived from data on treatment benefits and harms largely sourced from observational studies.

CONCLUSIONS

Predicted acceptance of longer and more frequent hemodialysis regimens substantially exceeds their use in current clinical practice. These findings underscore the need for robust data on clinical effectiveness of these more intensive regimens and more extensive consideration of patient choice in the selection of dialysis regimens.

Patients' perspectives of fluid management: A multicentre comparative study of home and incentre haemodialysis

BACKGROUND

There is increasing worldwide interest in person-centred care in haemodialysis and home haemodialysis (HHD). Intradialytic fluid management is a vital component of haemodialysis, and often a shared decision, yet patients' perspectives and experience of related decisions are largely unexplored.

OBJECTIVES

To explore the perspectives of patients receiving home or incentre haemodialysis (IHD), in relation to intradialytic fluid management.

DESIGN

A multicentre cross-sectional survey.

PARTICIPANTS

Eight hundred and thirty-nine patients receiving IHD and 99 patients receiving HHD, across six English renal units.

MEASUREMENTS

Self-reported measures of understanding, experiences and control of fluid management, and willingness to achieve target weight. An objective test of patients' ability to relate common signs and symptoms to fluid overload or excessive ultrafiltration.

RESULTS

Patients receiving HHD had greater knowledge than those receiving IHD (66.1% vs. 42.3%, p < 0.001) about causes of common signs and symptoms which remained when controlling for age, education and years since beginning haemodialysis. Patients receiving HHD felt more in control of and had greater self-reported adherence to fluid management (p < 0.01), yet knowledge gaps existed in both cohorts.

CONCLUSIONS

Greater patient knowledge and its practice in HHD may contribute to improved fluid balance and outcomes. Whilst patient selection may contribute towards these differences, the training patients receive when opting for HHD and subsequent experience are likely to be key contributing factors. Integrating aspects of education on fluid management from HHD training programmes should be considered in IHD, and further targeted, robust education remains an unmet need.

Determinants of active energy expenditure in haemodialysis patients

BACKGROUND

Less active haemodialysis patients have an increased risk of mortality. We wished to determine which factors were associated with active energy expenditure (AEE), METHODS: We used the validated recent physical activity questionnaire to determine AEE, and estimated dietary protein intake and creatinine generation rates. We measured extracellular and total body water ratio (ECW/TBW) and appendicular lean muscle with bioimpedance, and arm strength by hand grip strength (HGS). Patients were graded using the Charlson co-morbidity, and the Clinical Frailty Score (CFS).

RESULTS

AEE was calculated in 98 patients (64 male), mean age 62.1±15.5 years, and AEE was negatively associated with CFS (r=-0.48), ECW/TBW (r=-0.47), and age (r=-0.4), all p<0.001, Charlson co-morbidity score (-0.27, p=0.007), and positively with serum creatinine (r=0.38, p<0.010), and HGS (r=0.25, p=0.016). Although protein nitrogen accumulation and creatinine generation were associated with resting energy expenditure (r=0.7 and r=0.44 respectively, both p<.0001), neither were associated with AEE. On multivariable analysis only CFS remained independently associated with AEE (β-0.031, 95% limits -0.057 to -0.004, p=0.024), although both age (negative p=0.07), and ALM (positive p=0.081) were retained in the model.

CONCLUSIONS

We found that AEE was lower with increasing frailty, age, loss of cell mass, co-morbidity and inflammation, and greater AEE in patients with higher serum creatinine and albumin, and greater muscle strength on univariate analysis, but only frailty remained independently associated on multivariable analysis. Whether exercise programmes designed to increase AEE in haemodialysis patients can improve frailty scores, and so reduce mortality risk reman to be determined. This article is protected by copyright. All rights reserved.

Physical activity and exercise recommendations for people receiving dialysis: A scoping review

INTRODUCTION

Remaining physically active is important to patients undertaking dialysis, however, clinical recommendations regarding exercise type, timing, intensity, and safety precautions vary. The purpose of this scoping review was to analyse and summarise recommendations for physical activity and exercise for people undertaking dialysis and identify areas that require further research or clarification.

MATERIALS AND METHODS

A scoping review of literature from five bibliographic databases (Medline, Scopus, Web of Science, CINAHL, and SPORTDiscus) was conducted. Eligible articles included consensus guidelines, position statements, reviews, or clinical practice guidelines that included specific physical activity and exercise recommendations for people undertaking dialysis. Key search terms included "kidney disease" OR "kidney failure" OR "chronic kidney disease" OR "end stage kidney disease" AND guideline* OR consensus OR "position statement" OR prescription OR statement AND exercise OR "physical activity". Hand searching for relevant articles in all first twenty quartile 1 journals listed on SCImago under 'medicine-nephrology' and 'physical therapy, sports therapy and rehabilitation' using the terms 'exercise and dialysis' was undertaken. Finally, home pages of key societies and professional organisations in the field of sports medicine and nephrology were searched.

RESULTS

The systematic search strategy identified 19 articles met the inclusion criteria. Two were specific to pediatric dialysis and three to peritoneal dialysis. Whilst many publications provided recommendations on aerobic exercise, progressive resistance training and flexibility, few provided explicit guidance. Recommendations for the intensity, duration and frequency of aerobic and resistance training varied. Discrepancies or gaps in guidance about precautions, contraindications, termination criteria, progression, and access site precautions were also apparent.

CONCLUSION

Future guidelines should include specific guidance regarding physical activity, safety precautions, and timing and intensity of exercise for individuals who undertake dialysis. Collaborative multidisciplinary guideline development and appropriate exercise counselling may lead to increased participation in physical activity and exercise and facilitate better patient outcomes.