Ecological Momentary Assessment to Explore Fatigue, Mood, and Physical Activity Levels in People Receiving Peritoneal Dialysis.

Introduction: Fatigue is a frequent and debilitating symptom that contributes to poor quality of life for people receiving peritoneal dialysis. Ecological momentary assessment using mobile technology (mEMA) is a novel survey technique that can collect symptom data in real-time and has not been trialed in a peritoneal dialysis cohort. The study aimed to explore real-time fluctuations and associations between fatigue, mood, and physical activity using mEMA. Methods: Adults receiving peritoneal dialysis completed fatigue and mood scales, via a mobile application (app), 5 times daily for 7 days and, concurrently wore an accelerometer. A feasibility questionnaire was completed on the eighth day. Results: Forty-eight adults completed the study. Within-day fatigue fluctuations were observed with severity lowest during mid-morning to early afternoon and peaking at bedtime. Associations between fatigue and mood were observed with a 1-unit change in mood score conferring a 5.2-unit change in fatigue (P < 0.01). Higher volume of physical activity was associated with lower fatigue and enhanced mood. Overall adherence to the app-based surveys was 73% with most participants reporting mobile phones and the mEMA app being easy to use. Conclusion: People receiving peritoneal dialysis experience within day and day-to-day fluctuations in fatigue that appear highly variable. Higher fatigue severity was associated with poorer mood and lower physical activity levels with future studies required to explore if physical activity-based interventions could be a potential strategy for the management of these symptoms. Furthermore, mEMA, and mobile phones, were feasible to capture symptom data with potential to be employed in future research or, as part of improved care.

A Systematic Review of Online Resources for the Dietary Management of Hyperphosphatemia in People With Chronic Kidney Disease.

OBJECTIVE: Internet search engines and social media websites are prominent and growing sources of dietary information for people with chronic kidney disease (CKD) and their healthcare providers. However, nutrition therapy for CKD is undergoing a paradigm shift, which may lead to inconsistent advice for managing hyperphosphatemia. The aim of this study was to summarize and evaluate online resources for phosphorus-specific nutrition therapy. DESIGN AND METHODS: Patient-facing resources were collected from Google, Yahoo, and Facebook in June-July 2021. Using nine independent search terms, the first 100 hits were reviewed. Dietary advice for food types, food groups, food subgroups, and individual food items was categorized as "restricted," "recommended," "mixed," and "not mentioned." Information on publication date, source, and author(s), phosphorus bioavailability, and demineralization were also collected. RESULTS: After removing duplicates, 199 resources from Google and Yahoo and 33 from Facebook were reviewed. Resources ranged from 2005 to 2021 and were primarily authored by registered dietitians and medical doctors (65% and 31%, respectively). Dietary advice mostly focuses on restricting high-phosphorus foods and phosphorus additive-based processed foods. Dietary restrictions were generally consistent with the traditional low-phosphorus diet, which targets whole grains, dairy, and plant-based protein foods, although major inconsistencies were noted. Phosphorus bioavailability and demineralization were rarely mentioned (16% and 8%, respectively). Similar findings were found on Facebook, but the limited number of resources limited meaningful comparisons. CONCLUSION: Results showed that online resources for phosphorus-specific nutrition therapy are highly restrictive of heart-healthy food items and contain significant inconsistencies. Given the widespread and increasing use of online resources by people with CKD and health care professionals to inform dietary choices, efforts are urgently needed to establish consensus for phosphorus-specific nutrition therapy. Until then, the findings of this study provide a basis for increasing awareness of the potential for confusion arising from online resources.

'Phos'tering a Clear Message: The Evolution of Dietary Phosphorus Management in Chronic Kidney Disease.

Phosphorus is a vital nutrient, but disturbances in phosphorus homeostasis are central to chronic kidney disease-mineral and bone disorder. To minimize disturbances, traditional dietary guidance focused on a numerical phosphorus target leading to the exclusion of many healthy foods and implementation challenges. Contemporary phosphorus guidance focuses on dietary source, avoiding additives, and emphasizing low-phosphorus bioaccessibility foods, leading to a more liberal approach. Additional work is needed to demonstrate the efficacy of these contemporary approaches and understand the influence of specific foods, processing, and cooking methods. Unfortunately, patient education using traditional and contemporary strategies may give mixed messages, particularly related to plant-based foods. Thus, greater clarity on the effects of specific foods and dietary patterns may improve phosphorus education. This review aims to discuss the evolution of dietary phosphorus management while highlighting areas for future research that can help move the field toward stronger evidence-based guidance to prevent and treat hyperphosphatemia.

Deconstructing Disease-Related Malnutrition: A New Assessment Framework for Clinical Practice.

Protein-energy wasting (PEW) is a key cause of functional impairment and poor health outcomes in people with chronic kidney disease. While PEW can be mitigated with nutrition therapy, it is a complex myriad of disorders with numerous interacting etiologies and corresponding presentations, which make it difficult to diagnose and manage in practice. A variety of scoring rubrics have been developed to facilitate malnutrition assessment. Although these tools have greatly benefited the recognition and treatment of PEW, the typical format of grading specified PEW indicators has the potential to overlook or overstate highly relevant individual-specific factors. This review presents a simple framework for malnutrition assessment that can be used to complement and evaluate conventional assessment tools. Unlike standard tools, which are designed to identify and rate malnutrition risk and severity, the malnutrition framework is conceptual model that organizes PEW assessment into three distinct, but interacting facets of PEW risk: nutrient balance, nutrition status, and malnutrition risk. The new framework encourages critical thinking about PEW risk that may help clinicians plan and interpret assessments to efficiently and effectively manage this condition.

Revisiting Intradialytic Parenteral Nutrition: How Can We Apply the Evidence in Clinical Practice?

Intradialytic parenteral nutrition (IDPN) remains a controversial nutrition support practice in hemodialysis. Multiple reviews and evidence-based clinical practice guidelines have been published in the past 20 years. Despite essentially looking at the same evidence, conclusions and recommendations vary significantly, leading to widespread uncertainty among clinicians on the value of and indications for IDPN. This paper aims to bring a clinical perspective to the current state of evidence and clinical practice, recognizing the strengths and weaknesses of current evidence and the clinical questions that remain unanswered, as well as providing guidance for using IDPN in clinical practice. IDPN should be considered a strategy to complement spontaneous oral intake in clinically stable patients receiving maintenance hemodialysis or who have or are at risk of malnutrition and who have substantial but not adequate protein and/or energy intake. There is a clear need for robust randomized controlled trials evaluating the impact of IDPN in appropriately selected patients. Additionally, future trials should include patient-centered outcome measures such as appetite, spontaneous oral intake, quality of life, and reliable measures of nutritional status.

Combining exercise and nutrition in chronic kidney disease and dialysis: Can we learn from the performance nutrition of athletes?

The benefits of exercise interventions in individuals with chronic kidney disease have been widely reviewed; however, exercise has not yet been incorporated into routine clinical practice. In athletic populations, the goals of exercise training are to improve a specific aspect of physical performance such as strength or endurance, to ultimately optimize physical performance. This contrasts with many chronic kidney disease exercise studies where the goals are more aligned to a minimal effect, such as prevention of decline in physical function, frailty or protein energy wasting (PEW), weight loss for cardiovascular disease risk reduction, and risk minimization for mortality. In athletic populations, there are common targeted nutrition strategies used to optimize physical performance. In this review, we consider the evidence for and potential benefits of targeted nutrition strategies to complement well-designed exercise interventions to improve physical performance in people with chronic kidney disease and dialysis. Overall, we found a small number of studies using targeted protein supplementation in combination with a variety of exercise protocols; however, results were mixed. Future studies in people with chronic kidney disease should optimize acute (pre, during, and postexercise) and chronic nutritional status, utilizing targeted nutrition interventions proven in athletes to have benefit.

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.

Physical activity and exercise in peritoneal dialysis: International Society for Peritoneal Dialysis and the Global Renal Exercise Network practice recommendations.

Life participation requiring physical activity and physical function is a key patient-reported outcome for people receiving peritoneal dialysis (PD). Clinician guidance is required from multidisciplinary sources regarding exercise and activity advice to address the specific needs of this group. From August 2020 through to June 2021, the Global Renal Exercise Network and the International Society for Peritoneal Dialysis reviewed the published literature and international clinical experience to develop a set of clinical practice points. A set of questions relevant to physical activity and exercise were developed from the perspective of a person receiving PD and were the basis for the practice point development. The GRADE framework was used to evaluate the quality of evidence and to guide clinical practice points. The review of the literature found sparse quality evidence, and thus the clinical practice points are generally based on the expert consensus of people receiving PD, PD exercise expert clinicians and experienced PD exercise researchers. Clinical practice points address timing of exercise and activity (post-catheter insertion, peritoneal space empty or full), the uptake of specific activities (work, sex, swimming, core exercise), potential adverse outcomes related to activity and exercise (exit site care, perspiration, cardiovascular compromise, fatigue, intra-abdominal pressure), the effect of exercise and activity on conditions of interest (mental health, obesity, frailty, low fitness) and exercise nutrition.

Gastrointestinal symptom burden and dietary intake in patients with chronic kidney disease.

BACKGROUND: Gastrointestinal (GI) symptoms can present a significant burden to patients with chronic kidney disease (CKD) but the reported prevalence is inconsistent. OBJECTIVE: To examine the GI burden and dietary intake in patients with CKD with or without dialysis. METHODS: This was a cross-sectional study of 216 adults, recruited from outpatient and dialysis clinics, with CKD stage 4 or 5 not receiving dialysis (CKD-ND), or receiving haemodialysis (HD) or peritoneal dialysis (PD). Three questionnaires were administered: the Bristol Stool Form Scale (BSFS); a modified Gastrointestinal Symptom Rating Scale and a short Food Frequency Questionnaire. Outcomes were stool frequency and consistency, GI symptoms and dietary intake. RESULTS: Data were collected from 216 patients (mean age, 63 years [95% CI: 61, 65]; 63% males; CKD-ND: n = 134; HD: n = 67; PD: n = 15). Mean stool frequency for all groups was one bowel action per day (p = .45) and consistency was normal (BSFS type 4, p = .95). Overall GI symptom burden was low but several symptoms occurred at least "most of the time" including "tiredness/lethargy" (54% of participants), "reduced appetite" (29%), "early satiety" (25%) and "change in taste" (15%). Low intakes of fresh fruit, vegetables, whole-grains and legumes were found. No associations were observed between diet and GI symptoms. CONCLUSION: The overall GI symptom burden was low, but >15% of participants reported several symptoms as occurring most to all of the time. Low intakes of fresh fruit, vegetables, whole-grains and legumes were observed in all CKD patients.

Ecological momentary assessment to explore fatigue, mood and physical activity levels in people receiving peritoneal dialysis: A study protocol.

INTRODUCTION: Fatigue is a frequent and debilitating symptom for people with end-stage kidney disease (ESKD) receiving dialysis. Ecological momentary assessment (EMA) allows real-time data capture of day-to-day and diurnal variations. EMA has been used to study haemodialysis-related fatigue but not in people receiving peritoneal dialysis who are unique in their physical, environmental and logistical characteristics. The aim of this study is to explore the real-time associations between fatigue and mood (EMA mobile application) and objective physical activity levels (accelerometry) in people with EKSD receiving peritoneal dialysis. METHOD: A 7-day intensive longitudinal study will be conducted. People receiving peritoneal dialysis within South Australia will be invited to participate. Five times throughout the day, participants will be prompted to answer 18 questions relating to fatigue (Visual Analogue Scale to Evaluate Fatigue Severity) and a single question for mood (Visual Analogue Mood Scale). Participants will continuously wear a GENEActiv accelerometer to capture physical activity levels during the 7-day period. At the completion of the data collection, participants will answer questions to evaluate the feasibility and acceptability of using EMA. DISCUSSION: This study will be the first to explore the real-time relationships between fatigue, mood and physical activity in people with ESKD receiving peritoneal dialysis. Understanding the fluctuations people experience and the relationships between mood and physical activity and fatigue will inform clinical management and well-being intervention development.

Validity and Reliability of Hand-Held Dynamometry for Abdominal Flexion Muscular Assessment.

CONTEXT: Abdominal musculature underpins core stability, which can allow for optimal performance in many activities of daily living (eg, walking and rising from a chair). Therefore, assessment of the abdominal muscles poses as an important consideration for clinicians in order to identify people at risk of injury or functional decline. OBJECTIVE: This study aimed to build on the limited amount of knowledge surrounding abdominal muscle strength assessments by investigating the validity and reliability of hand-held dynamometry (HHD) for the assessment of isometric abdominal flexion strength. STUDY DESIGN AND PARTICIPANTS: Comparative analysis for validity and test-retest reliability was employed on a cohort of apparently healthy individuals. HHD was compared with the criterion, isokinetic dynamometry, through an isometric contraction of trunk flexion on both instruments. Hand-held dynamometry assessments only were performed on a subsequent day for reliability analysis. The peak values for all assessments were recorded. RESULTS: A total of 35 participants were recruited from the University of South Australia and the general public. Comparative analysis between the HHD and isokinetic dynamometer showed good agreement (intraclass correlation coefficients = .82), with the Bland-Altman plots confirming no proportional bias. Reliability analysis for the HHD reported good consistency (intraclass correlation coefficients = .87). CONCLUSION: HHD together with the participant setup (supine, trunk flexed, and supported at 25° with the legs horizontal and remaining unfixed) is a valid and reliable tool to assess isometric abdominal flexion strength.

Modifiable Physical Factors Associated With Physical Functioning for Patients Receiving Dialysis: A Systematic Review.

BACKGROUND: Patients receiving dialysis have reduced physical function, which is associated with unfavorable clinical outcomes and decreased quality of life. The authors aimed to identify and explore modifiable physical factors associated with physical function for patients receiving dialysis. METHODS: Searches were performed in MEDLINE, Embase, Ovid Emcare, and The Cochrane Library in October 2018. Etiological studies involving dialysis populations that report association or predictive statistics between a modifiable physical factor and physical function were eligible for inclusion. Predictor variables were (1) modifiable via exercise and (2) considered an impairment in the International Classification of Functioning, Disability and Health. RESULTS: Of 5384 titles screened, 23 studies were included. Thirteen studies focused on physical activity levels and muscle strength and the relationship with physical function while 2 studies investigated sedentary behavior. Twenty-one studies focused on hemodialysis populations. Studies related to physical activity levels displayed a moderately strong relationship with physical function, whereas muscle strength displayed a predominantly weak to moderate relationship. CONCLUSIONS: Physical activity levels, sedentary behavior levels, and muscle strength are related to physical function status for patients receiving dialysis. There is a need for robust longitudinal data to confirm the results of this investigation and for more focus on populations receiving peritoneal dialysis.

Gastrointestinal symptoms in patients receiving dialysis: A systematic review.

AIM: The aim of the present study was to describe the prevalence of all gastrointestinal (GI) symptoms reported by dialysis patients, as well as the tools being used for diagnosis. GI symptoms are commonly reported in patients having haemodialysis (HD) and peritoneal dialysis (PD), but there are multiple definitions and assessment tools reported in the literature. METHODS: A comprehensive systematic review was undertaken using five databases (Embase, Medline, CINAHL, Psycinfo and Web of Science) between 1996 and 2017. Articles were critically appraised using the Newcastle Ottawa Scale (NOS). Data collected were analyzed in a Microsoft Excel spreadsheet. RESULTS: Thirty studies (24 cross-sectional, six cohort) met the inclusion criteria. In total 5161 patients were studied (3804 HD and 1507 PD). Fifteen studies included HD, five included PD and 10 included both dialysis modalities. GI symptoms were heterogeneous, with the reported prevalence highly dependent on the definitions used, inclusion/exclusion criteria, assessment tools and methods used. The most prevalent symptoms were constipation, indigestion, abdominal pain and reflux. Medication use and dietary data were poorly reported. The most common tools used were Gastrointestinal Symptom Rating Scale (GSRS), Rome II and Rome III. Constipation was more common in HD patients than PD patients. Indigestion, abdominal pain and reflux were commonly reported in both dialysis modalities. CONCLUSIONS: Gastrointestinal symptoms are highly prevalent in people on dialysis; however, the evidence base is limited and further investigation of preventable causes and potential interventions such as medications and diet are required in future research.

Bowel health in chronic kidney disease: Patient perceptions differ from clinical definitions.

BACKGROUND: The bowel health of those with chronic kidney disease (CKD) can be affected by medications, fluid/dietary allowances, reduced activity and pre-existing medical conditions. Patient perceptions of their bowel health can differ from those of health care professionals and the burden of gastrointestinal symptoms could be inaccurately reported. METHODS: Adults with CKD, including those undergoing haemodialysis, peritoneal dialysis and kidney transplant from four South Australian hospitals enrolled in the study. Participants completed a five-item questionnaire, to investigate their perception of bowel health compared with clinical criteria for 'normal and abnormal' bowel health using the Bristol Stool Form Scale, bowel frequency and reported symptoms. RESULTS: A total of 324 individuals completed the questionnaire. Of those with clinically defined 'abnormal' bowel health (n = 180), 50.6% perceived their bowels as 'normal' or 'more normal than abnormal'. Only 6% of this clinically 'abnormal' group perceived their bowel health as abnormal. Of those with clinically defined 'normal' bowel health (n = 144), 16% perceived their bowel health as 'abnormal', 'more abnormal than normal' or 'variable'. Fifty-seven percent of patients with clinically defined 'abnormal' bowel health were not taking any treatments. Peritoneal dialysis recipients were the highest users of treatments to improve bowel function, with 62% using 1 or more treatment. CONCLUSIONS: It is common for patients with CKD to experience signs and symptoms of abnormal bowel health. There is a disconnect between patient perceptions and clinical definitions of normal or abnormal bowel health. Clinical care team members must carefully obtain and clarify patient-reported symptoms related to bowel function in order to help ensure recommendations and use of appropriate treatments.

Weight management strategies for those with chronic kidney disease: A consensus report from the Asia Pacific Society of Nephrology and Australia and New Zealand Society of Nephrology 2016 renal dietitians meeting.

AIM: The aim of the present study was to develop a consensus report to guide dietetic management of overweight or obese individuals with chronic kidney disease (CKD). METHODS: Six statements relating to weight management in CKD guided a comprehensive review of the literature. A summary of the evidence was then presented at the renal nutrition meeting of the 2016 Asia Pacific Society of Nephrology and Australia and New Zealand Society of Nephrology. Majority agreement was defined as group agreement on a statement of between 50-74%, and consensus was considered ≥75% agreement. The recommendations were developed via a mini Delphi process. RESULTS: Two statements achieved group consensus: the current guidelines used by dietitians to estimate energy requirements for overweight and obese people with CKD are not relevant and weight loss medications may be unsafe or ineffective in isolation for those with CKD. One statement achieved group agreement: Meal replacement formulas are safe and efficacious in those with CKD. No agreement was achieved on the statements of whether there is strong evidence of benefit for weight loss prior to kidney transplantation; whether traditional weight loss strategies can be used in those with CKD and if bariatric surgery in those with end stage kidney disease is feasible and effective. CONCLUSION: There is a limited evidence base to guide the dietetic management of overweight and obese individuals with CKD. Medical or surgical strategies to facilitate weight loss are not recommended in isolation and require a multidisciplinary approach with the involvement of a skilled renal dietitian.

Nutrition in Renal Supportive Care: Patient-driven and flexible.

Renal Supportive Care is an alternative treatment pathway in advanced chronic kidney disease that is being increasingly adopted, particularly in the elderly. Renal Supportive Care uses principles of palliative care and has been developed to enhance the care for dialysis patients with a high symptom burden and those being managed on a non-dialysis pathway. Nutrition management is often an under-recognized component of care and can play an important role in improving patients' quality of life to reduce symptom burden, support physical function and independence and provide appropriate counselling to patients and their families to ensure the goals of Renal Supportive Care are met. Nutrition interventions need to target patient and treatment goals, with frequent monitoring to ensure patient needs are being met. This review outlines available literature on this topic and suggests some practical ways in which nutrition can be enhanced for these patients.

Nutritional status of haemodialysis patients: comparison of Australian cohorts of Aboriginal and European descent.

AIM: It is not known whether nutritional status differs between Australian Aboriginal and non Aboriginal haemodialysis subjects. The aim of this study was to investigate the nutritional status of Australian Aboriginal and non-Aboriginal haemodialysis subjects at satellite dialysis centres. METHOD: Seventy-six (25 Aboriginal, 51 non-Aboriginal) prevalent haemodialysis patients were enrolled in a 3-month cross-sectional study. Each month anthropometric and biochemical measurements were collected. Nutritional status (diet history, patient-generated subjective global assessment (PG-SGA), handgrip strength) was assessed by a dietitian. RESULTS: PG-SGA detected mild to moderate malnutrition in 35% of Aboriginal patients and 25% of non-Aboriginal patients. The overall physical rating on the PG-SGA was significantly higher in Aboriginal patients, indicating the presence of a greater deficit in muscle mass in this population. Inter-dialytic weight gain was significantly greater in Aboriginal subjects (median [range] 3.0 [2.1-5.7] vs 2.5 [-0.3-5.0] kg, P<0.001). Glucose and HbA1c were significantly higher in Aboriginal subjects with diabetes than in non-Aboriginal patients with diabetes (median [range] 9.4 [4.9-23.4] vs 5.7 [3.1-12.9], P=0.002; 7.0 [5.2-11.0] vs 5.8 [4.6-9.0], P<0.000; respectively). These findings occurred in the setting of each cohort having adequate dialysis parameters (median Kt/V of >1.6 and median normalized protein catabolic rate 1.5). Difficulties were encountered in obtaining dietary information from Aboriginal subjects using the diet history method. CONCLUSION: Subjects had acceptable parameters of dialysis adequacy; however, 35% had evidence of malnutrition. Further research should focus on establishing a knowledge base for the nutritional management for Aboriginal dialysis subjects, and the development of a validated individual dietary assessment method for use in this population group.

Body mass index and postoperative complications in kidney transplant recipients.

BACKGROUND: There is a growing number of overweight and obese patients receiving kidney transplants, despite elevated body mass index (BMI) being associated with postoperative complications. Understanding associations between BMI and complications would allow more objectivity when recommending patients for transplantation or otherwise. METHODS: We analysed a retrospective cohort of 508 adult patients who received primary kidney grafts at a single centre in South Australia, 2002-2009, using hospital records and Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) data. Complications within 1 year of transplantation were classified into: surgical, wound, urological, delayed graft function, early nephrectomy and admission to intensive care unit (ICU). RESULTS: Overall, 62% of transplant recipients had a BMI above 25 kg/m(2) at transplant. Higher BMI was associated with an increased risk of wound complications (P < 0.001), early nephrectomy (P = 0.002) and delayed graft function (P = 0.03), but not associated with surgical or urological complications, or ICU admission. These associations were stronger for Indigenous Australians than other patients, especially for surgical complications. There was no BMI value above which risks of complications increase substantially. CONCLUSION: Delayed graft function is an important determinant of patient outcomes. Wound complications can be serious, and are more common in patients with higher BMI. This may justify the use of elevated BMI as a contraindication for transplantation, although no obvious cut-off value exists. Investigations into other measures of body fat composition and distribution are warranted.