Evidence supporting the use of a subjective staff evaluation to assess the benefit of rehabilitation in hemodialysis patients undergoing inpatient rehabilitation.

BACKGROUND: We questioned whether the introduction of a subjective evaluation of patient-specific goals, could be used as a valid method to assess the effectiveness of inpatient rehabilitation. METHODS: In this prospective cohort study, all admissions to the UHN hemodialysis rehabilitation service between April 2013 and August 2016 were included. We introduced a system of subjective assessment, performed by the team at the time of admission and discharge. We evaluated Functional Independence Measure (FIM®) score and KDQoL for objective measures of physical function and patient-reported quality of life. RESULTS: A total of 201 patients were included. The median FIM score at discharge correlated well with the subjective staff evaluation. FIM score changes for those with evaluations for Success, Partial success, and Not Successful were 28 [interquartile range (IQR) 20-34], 24 [IQR18-31], 16 [IQR 11-34] respectively. The median PCS at discharge for those deemed to have Success was 37.4 [IQR31.0, 44.7], and for those with Partial success & Not Successful 28.8 [IQR 22.4, 39.2]. There was no correlation with MCS scores (55.2 [IQR 51.2, 60.2], 58.4 [IQR 50.1, 63.1] respectively). CONCLUSIONS: These results suggest the subjective staff evaluation is a brief but valid assessment of patient outcome for dialysis patients undergoing inpatient rehabilitation.

Loss of appendicular muscle mass in haemodialysis patients is associated with increased self-reported depression, anxiety and lower general health scores.

BACKGROUND: Previous reports have suggested an association between depression and nutritional status. To investigate whether there is an association with loss of muscle mass (sarcopenia), we screened HD patients for depression. METHODS: We screened for depressive symptoms using the Beck Depression Inventory-II (BDI-II), Hospital Anxiety and Depression Scale (HADS), and general health using the short form 36 (SF36), and additionally measured appendicular lean mass post-dialysis with segmental bioimpedance. RESULTS: We studied 113 patients, 84 (74.3%) male, mean age 64.9 ± 14.9 years, median duration of haemodialysis 27.0 (15.7-61.0) months, body mass index post-dialysis 25.2 (22.8-28.6) kg/m2, appendicular lean mass (ALM) index 6.98 (6.22-8.10) kg/m2. BDI-II 11 (4-17), HADS 10 (5-16.5), and SF36 average 43.3(36.6-48.4). Lower ALM index was associated with greater BDI-II and HADS depression scores (r = 0.29, p = 0.008; r = 0.27, p = 0.012) respectively, whereas higher ALM index was associated with increased SF36 physical functioning and general health (r = 0.34, p = 0.001; r = 0.26, p = 0.019), respectively on univariate analysis. On logistic regression, lower ALM index was independently associated with high HADS cut off ≥8 (standardised ß-0.31, p = 0.007). There were no associations with weight, body mass index or fat index. Greater extracellular water both pre- and post-dialysis was associated with reduced SF36 physical functioning (r = -0.24, p = 0.011, r = -0.22, p = 0.26), respectively. CONCLUSION: We report an association between ALM index measured by segmental bioimpedance and increased self-reported depression, anxiety and decreased general health. Whether treatment programs designed to improve muscle mass, can lead to reduced levels of depression, and anxiety and improved perceived general health, remains to be determined.

Does online haemodiafiltration reduce intra-dialytic patient symptoms?

INTRODUCTION: Patients often suffer from symptoms during dialysis. Haemodiafiltration (HDF) therapy has been suggested to be superior to standard haemodialysis (HD). To understand patients' experiences, we quantified the burden and duration of dialysis-associated symptoms to determine whether there was any difference between the modalities. METHODS: Symptom questionnaires (83.3%) were returned by 623 dialysis outpatients. Symptom scores were analysed using a visual analogue score. We compared symptom burdens during HD and HDF treatments and also whether the scores changed following a modality change to HDF. RESULTS: Among the patients, 55.7% were men, the median age was 65 years, 39.7% were diabetic, 26.4% were treated by HDF and the median unadjusted Charlson co-morbidity score was 6 (IQR 4-8). Fatigue (77.3%), intra-dialytic hypotension (76.4%), cramps (74.3%) and dizziness (63%) were the commonest symptoms reported, followed by headache (53.6%) and pruritus (52.2%). Although most symptoms were reported less frequently with HDF [median headache frequency score: HD: 1 (IQR 1-4) vs. HDF: 0 (IQR 0-2), p < 0.005]. There was no evidence of a reduction in symptom scores in patients switching from HD to HDF compared to those remaining on HD. CONCLUSION: Patient self-reporting shows that most patients frequently suffer symptoms. There was no evidence that switching to HDF improved symptoms in patients established on HD.

Conservative care for end-stage kidney disease: joint medical conference with the Renal Association, British Geriatrics Society and Association for Palliative Medicine.

Conservative care is one of the fastest-changing areas of renal medicine. Non-dialytic therapy is now established as a treatment option in most renal units in the UK. This conference reviewed the history of conservative management and examined the state of current practice. The challenges now faced include expanding the evidence base in this area, improving the information given to patients and their families to help them make a decision about treatment, and responding to changes in NHS funding to ensure continued provision of high-quality care.

Encapsulating Peritoneal Sclerosis.

Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis. In this review, we describe the clinical picture and histologic changes to the peritoneal membrane that are associated with EPS and provide an update on current diagnosis and management. We also discuss the recent studies that have suggested that the use of more biocompatible solutions containing lower concentrations of glucose degradation product that often are pH neutral in combination with a change in clinical practice (reducing glucose exposure and monitoring peritoneal membrane function) might ameliorate peritoneal degeneration, reduce the incidence of EPS, and minimize the severity of the disease.

Ageing Renal Patients: We Need More Collaboration between Geriatric Services and Nephrology Departments.

There has been a significant increase in the number of frail older patients diagnosed with advanced chronic kidney disease (CKD) over the past thirty years. These elderly patients have high levels of comorbidity, and as a consequence the face of renal medicine is changing-There is an increasing need to focus on traditionally geriatric areas of expertise such as falls prevention and rehabilitation, and to shift our emphasis onto improving patient well-being rather than longevity. Over the past decade, many nephrologists have found that they are already acting as de facto "amateur geriatricians". This denies patients both the benefits of specialist geriatric assessment, and equally importantly denies them access to the wider geriatric multidisciplinary team. This article describes the prevalence and underlying causes of the so-called "Geriatric Giants" in patients with advanced CKD, and discusses possible improvements in care that closer working with geriatricians could bring.

Conservative care of the patient with end-stage renal disease.

'Conservative care' is the management of end-stage kidney disease without dialysis, ie a palliative approach. It is now well established as the fourth treatment option alongside haemodialysis, peritoneal dialysis and transplantation, in the majority of UK renal centres.