Efficacy and safety of difelikefalin in the treatment of hemodialysis patients with pruritus: A meta-analysis and systematic review.

BACKGROUND: The incidence of pruritus associated with hemodialysis (HD) patients can be as high as 70%, and ~ 40% of patients suffer from moderate to severe systemic pruritus. Difelikefalin (CR845), a peripheral restrictor κ-opioid receptor agonist, activates opioid receptors on peripheral neurons and immune cells to relieve pruritus in patients. However, the clinical effect of difelikefalin on HD-related pruritus is unclear. Therefore, the purpose of this meta-analysis and systematic review was to investigate the safety and efficacy of difelikefalin in the treatment of HD-associated pruritus. OBJECTIVE: This study explored the efficacy and safety of difelikefalin in the treatment of pruritus in HD patients by systematic review and meta-analysis. MATERIALS AND METHODS: Randomized controlled trials on difelikefalin in the treatment of pruritus in HD patients were retrieved from PubMed, Embase, Cochrane Library, and Web of Science electronic databases. The retrieval deadline was January 1, 2023. Stata 15.0 software was used for data analysis of the included studies. RESULTS: A total of 4 randomized controlled trials were included, totaling 1,268 patients (736 patients in the experimental group and 532 patients in the control group). Results of the meta-analysis showed that, compared with the control group, difelikefalin could significantly improve the Worst Itch Numeric Rating Scale score (improvement > 3; risk ratio (RR) = 1.28, 95% confidence interval (CI) (1.07, 1.53)), decrease the 5-D itch score (standardized mean difference = -0.43, 95% CI (-0.55, -0.30)), and significantly improve adverse events (RR = 1.33, 95% CI (1.13, 1.56)). CONCLUSION: Although difelikefalin can improve itching symptoms in HD patients, it can also increase adverse reactions based on the current literature. Therefore, more studies are needed to further explore the safety and efficacy of difelikefalin treatment.

Prevalence and potential influencing factors for social frailty among community-dwelling older adults: a systematic review and meta-analysis.

OBJECTIVE: To explore the prevalence and potential influencing factors of social frailty among community-dwelling older adults from a global perspective. METHODS: Systematic searches were conducted on multiple databases including CNKI, VIP, Wanfang Data, CBM, Pubmed, Cochrane Library, Web of Science, and Embase from inception to January 9, 2024. Two researchers performed a thorough literature search, gathered data, and independently evaluated the quality of the articles. RESULTS: 2,426 literatures were examined, 45 were found to meet the specified criteria for inclusion, encompassing 314,454 participants. The combined prevalence of social pre-frailty and social frailty among community-dwelling older adults were found to be 34.5% and 21.1%, respectively. Depression, activities of daily living (ADL), physical inactivity, motor deficits, cognitive impairment, and physical frailty are potential risk factors. CONCLUSIONS: Social pre-frailty and social frailty are frequent challenges faced by older adults living in the community. The prevalence of these conditions has been on the rise in recent years, underscoring the importance of implementing effective interventions. Early identification and intervention for individuals at risk of social frailty are essential for promoting healthy and active aging globally.

Bioelectrical impedance phase angle combined with physical function predicts pre-frailty in maintenance hemodialysis patients: a prospective study.

BACKGROUND: The prevalence of pre-frailty is notably high among maintenance hemodialysis (MHD) patients. Pre-frailty, an early and reversible condition between non-frailty and frailty, can lead to adverse outcomes such as increased unplanned hospital admissions and a higher risk of other chronic diseases. Early identification and intervention of pre-frailty in MHD patients are crucial. This study aimed to establish a simple and effective model for screening and identifying MHD patients at high risk of pre-frailty by using 50 kHz-Whole Body Phase Angle (PhA) measured by bioelectrical impedance analysis (BIA), hand grip strength (HGS), the Five-Times-Sit-to-Stand Test (FTSST), and laboratory parameters, with a specific focus on gender differences. METHODS: This prospective cross-sectional study was conducted from September to December 2023 at the Wenjiang Hemodialysis Center in the Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China. A total of 244 MHD patients, including 130 males and 114 females, were enrolled, comprising 128 non-frail and 116 pre-frail individuals. Data were collected prospectively, including demographic information, physical measurements, and laboratory test results. All participants provided informed consent before enrollment. The FRAIL scale (FS) was used to assess pre-frailty in MHD patients. Grip strength was measured using an electronic grip strength tester, physical function was assessed using the Five-Times-Sit-to-Stand Test, and whole-body phase angle was measured using the InBody S10 device. RESULTS: A total of 244 MHD patients with a mean age of 53.75 ± 0.90 years were enrolled, including 130 males with a mean age of 54.12 ± 1.26 years and 114 females with a mean age of 53.32 ± 1.29 years. ROC curve analysis showed that in male patients, the AUC of PhA for predicting pre-frailty was 0.919, with a sensitivity of 94.5% and specificity of 91.3%, and a cutoff value of 6.05°; in female patients, the AUC of PhA was 0.870, with a sensitivity of 70.5% and specificity of 90.6%, and a cutoff value of 5.25°. The AUC of FTSST for screening pre-frailty in male patients was 0.827, with a sensitivity of 62.3% and specificity of 96.2%, and a cutoff value of 12.95 s; in female patients, the AUC of FTSST was 0.784, with a sensitivity of 67.3% and specificity of 84.0%, and a cutoff value of 12.95 s. Additionally, in male patients, the combination of PhA and FTSST resulted in an AUC of 0.930, with a sensitivity of 96.4% and specificity of 81.3%; in female patients, the AUC was 0.911, with a sensitivity of 78.7% and specificity of 92.5%. CONCLUSION: PhA measured by BIA, in combination with the Five-Times-Sit-to-Stand Test, serves as an effective screening tool and predictor of pre-frailty in MHD patients. The combination of PhA and FTSST shows enhanced diagnostic value in female patients, while PhA alone is sufficient for predicting pre-frailty in male patients. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2100051111), registered on 2021-09-13.

Middle-size molecule clearance as measured by ß2-microglobulin in high-flux versus low-flux dialysis and hemodiafiltration: A prospective randomized controlled trial.

BACKGROUND: Whereas most studies to date have mainly concentrated on the comparison between high-flux hemodialysis (HFHD) and hemodiafiltration (HDF), or HFHD and low-flux hemodialysis (LFHD) in relation to the clearance of ß2-microglobulin (ß2M) in HD patients, there have been few related to combined HFHD and HDF therapy. To compare the clearance of middle-sized molecules as measured by ß2M in HFHD versus LFHD and HDF. METHODS: A prospective, single-center, open-label, observer-blinded, randomized controlled trial was conducted at the West China Hospital of Sichuan University in China. Patients received either HFHD or LFHD and HDF 3 times a week with follow-ups at one and 3 months. The primary endpoint was the clearance of ß2M at 3 months. The secondary endpoints included hemodialysis-related adverse events, changes in anemia, states of nutrition, and inflammatory indices. RESULTS: After 3 months of treatment, the HFHD+HDF group achieved a higher satisfaction level than the LFHD+HDF group, with decreased serum ß2M concentrations (34.493 ± 7.257 vs. 43.593 ± 9.036 mg/L, p < 0.001) and elevated red blood cell counts (3.959 ± 0.742 vs. 3.602 ± 0.578 × 1012 /L, p = 0.015). Compared with baseline, both kinds of treatment led to increases in serum urea (t = -3.623, p = 0.001 vs. t = -4.240, p < 0.001), cholesterol (t = -2.511, p = 0.016 vs. t = -4.472, p < 0.001), and magnesium (t = -2.648, p = 0.011 vs. t = -3.561, p = 0.001). An elevated level of serum albumin (t = -2.683, p = 0.010) was observed only in the HFHD+HDF group. CONCLUSIONS: Combined therapy with HFHD and HDF has a beneficial effect on improving ß2M clearance, red blood cell management, and nutrition status in HD patients.

Prevalence, associated factors and clinical implications of medication literacy linked to frailty in hemodialysis patients in China: a cross-sectional study.

BACKGROUND: Maintenance hemodialysis (MHD) patients have complex medication regimens that require a high level of skill to interpret medication information. However, there is currently a lack of research evaluating the ability to read and understand medication labels in Chinese MHD patients. In addition, the relationship between frailty and medication literacy among MHD patients remains unclear. Therefore, this study aims to assess the potential factors affecting medication literacy in MHD patients and to explore the relationship between frailty and medication literacy. METHODS: This cross-sectional study was conducted using convenience sampling in West China Hospital of Sichuan University, China. Using a general questionnaire, we collected demographic, clinical and laboratory data. Medication literacy was assessed by the Chinese Medication Literacy Scale, and frailty was assessed by the FRAIL Scale. Univariate analyses examined potential factors associated with medication literacy. An ordered logistic regression was used to analyze the relationships between medication literacy and these factors. Spearman's correlation was used to assess the association between medication literacy and frailty. RESULTS: A total of 290 MHD patients were included in the analysis. Inadequate, marginal, and adequate medication literacy was found in 56 (19.3%), 153 (52.8%), and 81 (27.9%) patients, respectively. Ordered logistic regression revealed factors associated with inadequate medication literacy: age (OR = 0.281, 95% CI = 0.139-0.565, p < 0.001 for < 65 years); education (OR = 8.612, 95% CI = 3.524-21.046, p < 0.001 for ≤ primary school education; OR = 3.405, 95% CI = 1.683-6.887, p = 0.001 for junior high school education); presence of caregiver medication assistance (OR = 2.302, 95% CI = 1.173-4.516, p = 0.015); frailty (OR = 0.440, 95% CI = 0.216-0.893, p = 0.023 for frail patients); and high ß2-microglobulin (ß2-MG) (OR = 1.010, 95% CI = 1.002-1.019, p = 0.012). Spearman's analysis showed that medication literacy was negatively correlated with frailty in MHD patients (R=-0.189, p = 0.001). CONCLUSIONS: Medication literacy levels in MHD patients needed improvement and were associated with certain patient characteristics, including age, education level, presence of caregiver support, ß2-microglobulin levels, and risk of frailty. This study identified subgroups of MHD patients, such as those who were older, had lower education, had caregiver assistance, had high ß2-microglobulin levels, or were frail, to have inadequate medication literacy. These findings underscore the need for routine screening and targeted interventions to improve medication literacy in this population.

Use machine learning to help identify possible sarcopenia cases in maintenance hemodialysis patients.

BACKGROUND: Maintenance hemodialysis (MHD) patients often suffer from sarcopenia, which is strongly associated with their long-term mortality. The diagnosis and treatment of sarcopenia, especially possible sarcopenia for MHD patients are of great importance. This study aims to use machine learning and medical data to develop two simple sarcopenia identification assistant tools for MHD patients and focuses on sex specificity. METHODS: Data were retrospectively collected from patients undergoing MHD and included patients' basic information, body measurement results and laboratory findings. The 2019 consensus update by Asian working group for sarcopenia was used to assess whether a MHD patient had sarcopenia. Finally, 140 male (58 with possible sarcopenia or sarcopenia) and 102 female (65 with possible sarcopenia or sarcopenia) patients' data were collected. Participants were divided into sarcopenia and control groups for each sex to develop binary classifiers. After statistical analysis and feature selection, stratified shuffle split and Synthetic Minority Oversampling Technique were conducted and voting classifiers were developed. RESULTS: After eliminating handgrip strength, 6-m walk, and skeletal muscle index, the best three features for sarcopenia identification of male patients are age, fasting blood glucose, and parathyroid hormone. Meanwhile, age, arm without vascular access, total bilirubin, and post-dialysis creatinine are the best four features for females. After abandoning models with overfitting or bad performance, voting classifiers achieved good sarcopenia classification performance for both sexes (For males: sensitivity: 77.50% ± 11.21%, specificity: 83.13% ± 9.70%, F1 score: 77.32% ± 5.36%, the area under the receiver operating characteristic curves (AUC): 87.40% ± 4.41%. For females: sensitivity: 76.15% ± 13.95%, specificity: 71.25% ± 15.86%, F1 score: 78.04% ± 8.85%, AUC: 77.69% ± 7.92%). CONCLUSIONS: Two simple sex-specific sarcopenia identification tools for MHD patients were developed. They performed well on the case finding of sarcopenia, especially possible sarcopenia.

Relationship between modifiable lifestyle factors and chronic kidney disease: a bibliometric analysis of top-cited publications from 2011 to 2020.

BACKGROUND: Chronic kidney disease (CKD) affects 8 to 16% of the world's population and is one of the top ten important drivers of increasing disease burden. Apart from genetic predisposition, lifestyle factors greatly contribute to the incidence and progression of CKD. The current bibliometric analysis aims to characterize the current focus and emerging trends of the research about the impact of modifiable lifestyle factors on CKD. METHODS: We searched articles addressing the impact of modifiable lifestyle factors on the incidence and/or progression of CKD, published between 2011 and 2020, from the Science Citation Index Expanded (SCIE) database. An adjusted citation index, which considered both the original citation count and publication year, was derived for the selection of most-cited publications. Publishing trends, co-authorship network, keywords, and research hotspots were analyzed and visualized. RESULTS: Among the top 100 most influential articles, 32 were narrative reviews, 16 systematic reviews and/or meta-analysis, 44 clinical research, and 8 basic research. The United States occupied a dominant position in the perspective of article numbers and international partnerships, followed by European countries. The modifiable factors that drew the most and constant attention over the decade were diet or nutrition management reported in 63 papers, followed by obesity or body mass index (n = 27), and physical activity or exercises (n = 8). Alcohol consumption, fish oil, chain fatty-acids, and water-soluble vitamins were emerging hotspots identified in the recent most cited publications. CONCLUSIONS: Based on the bibliometric analysis of the most influential articles, our study provides a comprehensive description of publishing trends and research focus over a decade in the field of lifestyle factors' impact on CKD. Diet, obesity, and physical activity were factors receiving the most attention in this topic.

Exploring psychosocial factors associated with frailty incidence among patients undergoing maintenance hemodialysis.

AIM AND OBJECTIVE: We investigated the correlation between the frailty status of maintenance haemodialysis (MHD) patients and psychosocial factors. BACKGROUND: Varying degrees of frailty have been reported in MHD patients, which affect their quality of life. DESIGN: We adopted a cross-sectional design in this study. METHODS: Clinical data of 187 patients at our centre were collected from December 2017-June 2018 using a cross-sectional survey. Psychosocial factors were measured using the Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale, 10-item Connor-Davidson Resilience Scale (CD-RISC), Chronic Disease Self-Efficacy Scales and Perceived Social Support Scale. Frailty status was estimated using the fatigue, resistance, ambulation, illnesses and loss of weight (FRAIL) scale. Spearman's correlation and multiple logistic regression analysis were conducted to identify the risk factors for frailty. This study complied with the STROBE checklist. RESULTS: Of 187 patients, 11 cases (5.9%) of frailty were identified. Patient's age, comorbidities, parathyroid hormone level, sleep quality and depression were positively correlated with frailty (p < .05), while psychological resilience and social support were negatively correlated with frailty (p < .05). Logistic regression analysis revealed four risk factors for frailty among MHD patients, including age (p = .004), comorbidities (p = .023), depression (p = .023) and sleep disorders (p = .029). Conversely, protective factors included high psychological resilience (p = .019) and social support (p = .039). CONCLUSION: Among MHD patients, the risk factors for frailty included age, comorbidity, depression and sleep disturbance, whereas the protective factors included psychological resilience and social support. RELEVANCE TO CLINICAL PRACTICE: Frailty is not only common among older patients, but also among people of all age groups suffering from chronic diseases. Therefore, it is important to consider the health status of MHD patients and adopt targeted nursing strategies to alleviate symptoms of frailty and improve physical condition by the following ways: postpone the progress of comorbidities, improve sleep quality, control the symptoms of depression, foster psychological resilience and facilitate support from social and family.

The health-related quality of life among patients on maintenance haemodialysis: Evaluation using the "EQ-5D".

PURPOSE: We conducted a cross-sectional investigation of health-related quality of life (HRQOL) among maintenance haemodialysis (MHD) patients, and determined important predictive factors of HRQOL in these patients. METHODS: Psychological factors were evaluated with the Hospital Anxiety and Depression Scale (HADS), the Pittsburgh Sleep Quality Index (PSQI) and the General Self-Efficacy Scale (GSES). HRQOL was evaluated with the EQ-5D. Laboratory data (albumin, haemoglobin and C-reactive protein) were collected for medical evaluation. We also collected participants' demographic data, including gender, age, et al. This study was in compliance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. RESULTS: The mean EQ-5D score was 0.86 ± 0.12, mean HADS-anxiety score was 5.27 ± 3.41, mean HADS-depression score was 5.29 ± 3.58, mean PSQI score was 7.00 ± 4.23 and mean GSES score was 6.86 ± 2.03. Participants' mean haemoglobin was 108.18 ± 16.45 g/L, mean albumin was 41.80 ± 4.61 g/L and mean C-reactive protein was 8.88 ± 18.50 mg/L. HRQOL was negatively correlated with HADS-anxiety (r = -0.390, p < 0.001), HADS-depression (r = -0.385, p < 0.001), PSQI (r = -0.285, p < 0.001) and C-reactive protein (r = -0.198, p = 0.034). HRQOL was positively correlated with GSES (r = 0.205, p = 0.007). Age (p < 0.001), anxiety (p < 0.001), depression (p = 0.002), and postdialysis unemployment (p < 0.001) were independent risk factors for HRQOL. CONCLUSION: Different health interventions should be implemented to improve patients' HRQOL. RELEVANCE TO CLINICAL PRACTICE: The results will provide evidence for establishing healthcare interventions to maintain or improve HRQOL among this patient population.

Knowledge, attitude, and practice toward nutrition support and management among hemodialysis patients.

Nutrition support is an important care component for patients on hemodialysis. Also, patient self-management is important to maintaining proper nutritional intake during hemodialysis. This cross-sectional study investigated the knowledge, attitude, and practice (KAP) towards nutrition support and management among hemodialysis patients treated at the West China Hospital of Sichuan University between January and March 2023. Among 445 (95.91%) valid questionnaires, 58.43% were filled out by male patients. The knowledge, attitude, and practice scores were 11.44 ± 1.80 (possible range: 0-13), 30.29 ± 3.22 (possible range: 8-40), and 31.27 ± 5.67 (possible range: 8-40), respectively. Age > 60 years (OR = 0.487, 95%CI: 0.260-0.913, P = 0.025) and junior college or undergraduate or above (OR = 2.606, 95%CI: 1.621-4.189, P < 0.001) were independently associated with adequate knowledge. The knowledge (OR = 1.151, 95%CI: 1.024-1.294, P = 0.018) and female gender (OR = 0.632, 95%CI: 0.419-0.953, P = 0.029) were independently associated with positive attitude. The knowledge (OR = 1.404, 95%CI: 1.221-1.614, P < 0.001), attitude (OR = 1.146, 95%CI: 1.069-1.227, P < 0.001), age 51-60 years (OR = 1.879, 95%CI: 1.093-3.229, P = 0.022), and BMI of 24.0-27.9 kg/m2 (OR = 0.434, 95%CI: 0.269-0.700, P = 0.001) were independently associated with proactive practice. Hemodialysis patients showed adequate knowledge, positive attitudes, and proactive practice; however, there were also several gaps in knowledge and misconceptions regarding proper nutritional self-management. Accordingly, addressing these gaps and misconceptions through carefully designed and effectively implemented education is crucial for providing comprehensive guidance on optimal nutrition and self-management strategies.

Factors related to the disaster preparedness of patients on haemodialysis from Sichuan, China, during COVID-19: A cross-sectional study.

AIM: This study aimed to investigate personal preparedness among patients on haemodialysis (HD) and to examine the relationship among sociodemographic characteristics, attitudes toward disaster preparedness and personal preparedness behaviours during natural disaster incidents. DESIGN: A cross-sectional survey was conducted. METHODS: A convenience sampling method was used. A total of 446 participants from six areas of Sichuan province completed the online questionnaire study from February 27 to March 13, 2022. Sociodemographic characteristics, attitudes toward disaster preparedness and personal preparedness behaviours were measured. Descriptive statistics were used to analyse sociodemographic characteristics and attitudes toward disaster preparedness. The relationship among sociodemographic characteristics, attitudes toward disaster preparedness and personal preparedness behaviours were assessed using ordinal regression. Statistical significance was defined as p < 0.05. RESULTS: A total of 446 participants completed the survey. Of these, 42.15% (N = 188) were poorly prepared, 26.23% (N = 117) were moderately prepared and 31.61% (N = 141) were highly prepared. Ordinal regression showed that knowing about disaster preparedness (Odds Ratio (OR) = 1.691, 95% Confidence Interval (CI) = 1.081-2.644, p = 0.021), participating in disaster evacuation exercises (OR = 2.519, 95% CI = 1.595-3.977, p < 0.001) and learning about disaster preparedness (OR = 2.421, 95% CI = 1.542-3.802, p < 0.001) were associated with high preparedness. Compared to patients with a university degree or higher, patients with a junior high school education or lower (OR = 3.491, 95% CI = 1.760-6.925, p < 0.001) and senior high school degree (OR = 2.052, 95% CI = 1.038-4.057, p = 0.039) were associated with high preparedness. Patients who felt very confident and could deal with all their needs (OR = 3.878, 95% CI = 2.904-7.181, p < 0.001) or patients who felt confident and could meet some of their needs (OR = 1.949, 95% CI = 1.124-3.379, p = 0.017) had higher preparedness than those who felt less confident and were not well prepared to take care of their needs. PATIENT OR PUBLIC CONTRIBUTION: After obtaining each participant's consent, they filled out the online questionnaire using their own or a relative's cell phone while undergoing HD. IMPLICATION FOR PRACTICE: It is essential that patients should be educated not only on medical specialty topics, but also on general disaster preparedness. Medical institutions should improve and reinforce preparation training among targeted populations. The low level of preparedness is partly due to the lack of participation of patients in disaster preparedness programs. Dialysis center managers should be urged to implement such programs at their centers.

A machine learning-based assistant tool for early frailty screening of patients receiving maintenance hemodialysis.

PURPOSE: To develop an assistant tool based on machine learning for early frailty screening in patients receiving maintenance hemodialysis. METHODS: This is a single-center retrospective study. 141 participants' basic information, scale results and laboratory findings were collected and the FRAIL scale was used to assess frailty. Then participants were divided into the frailty group (n = 84) and control group (n = 57). After feature selection, data split and oversampling, ten commonly used binary machine learning methods were performed and a voting classifier was developed. RESULTS: The grade results of Clinical Frailty Scale, age, serum magnesium, lactate dehydrogenase, comorbidity and fast blood glucose were considered to be the best feature set for early frailty screening. After abandoning models with overfitting or poor performance, the voting classifier based on Support Vector Machine, Adaptive Boosting and Naive Bayes achieved a good screening performance (sensitivity: 68.24% ± 8.40%, specificity:72.50% ± 11.81%, F1 score: 72.55% ± 4.65%, AUC:78.38% ± 6.94%). CONCLUSION: A simple and efficient early frailty screening assistant tool for patients receiving maintenance hemodialysis based on machine learning was developed. It can provide assistance on frailty, especially pre-frailty screening and decision-making tasks.

Moderating Effects of Forgiveness on Relationship Between Empathy and Health-Related Quality of Life in Hemodialysis Patients: A Structural Equation Modeling Approach.

CONTEXT: Health-related quality of life (QOL) is a recommended clinical tool to assess hemodialysis patients and a primary end point to observe the effectiveness of overall disease management. Empathy is associated with positive outcomes such as pain relief and reduced anxiety and distress. Numerous studies have tested the relationships among empathy, forgiveness, and QOL; however, a mechanism of forgiveness has not been fully explored in hemodialysis patients. OBJECTIVES: To test the relationship among empathy and health-related QOL and confirm the moderating effects of forgiveness on relationship between empathy and health-related QOL among hemodialysis patients. METHODS: In a descriptive cross-sectional study conducted from September to December 2017, 457 hemodialysis patients from five hospitals filled out the Heartland Forgiveness Scale, Interpersonal Reactivity Index-C, Kidney Disease Questionnaire, and general information. The data were analyzed using SPSS, and structural equation modeling was used to address the relationships among empathy, forgiveness, and health-related QOL. RESULTS: Empathy was significantly positively associated with health-related QOL. The proposed model had a good fit to the data. Forgiveness was found to play a partial mediating role between empathy and health-related QOL. CONCLUSION: The results imply that empathy significantly directly and indirectly influences health-related QOL. Empathy among hemodialysis patients should be monitored and effectively managed to improve positive effects on their health-related QOL. Nurses should consider implementing empathy interventions with an emphasis on building forgiveness strategies to help hemodialysis patients improve their health-related QOL.