Impact of Prior Abdominal Procedures on Peritoneal Dialysis Catheter Outcomes: Findings From the North American Peritoneal Dialysis Catheter Registry.

RATIONALE & OBJECTIVE: A history of prior abdominal procedures may influence the likelihood of referral for peritoneal dialysis (PD) catheter insertion. To guide clinical decision making in this population, this study examined the association between prior abdominal procedures and outcomes in patients undergoing PD catheter insertion. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Adults undergoing their first PD catheter insertion between November 1, 2011, and November 1, 2020, at 11 institutions in Canada and the United States participating in the International Society for Peritoneal Dialysis North American Catheter Registry. EXPOSURE: Prior abdominal procedure(s) defined as any procedure that enters the peritoneal cavity. OUTCOMES: The primary outcome was time to the first of (1) abandonment of the PD catheter or (2) interruption/termination of PD. Secondary outcomes were rates of emergency room visits, hospitalizations, and procedures. ANALYTICAL APPROACH: Cumulative incidence curves were used to describe the risk over time, and an adjusted Cox proportional hazards model was used to estimate the association between the exposure and primary outcome. Models for count data were used to estimate the associations between the exposure and secondary outcomes. RESULTS: Of 855 patients who met the inclusion criteria, 31% had a history of a prior abdominal procedure and 20% experienced at least 1 PD catheter-related complication that led to the primary outcome. Prior abdominal procedures were not associated with an increased risk of the primary outcome (adjusted HR, 1.12; 95% CI, 0.68-1.84). Upper-abdominal procedures were associated with a higher adjusted hazard of the primary outcome, but there was no dose-response relationship concerning the number of procedures. There was no association between prior abdominal procedures and other secondary outcomes. LIMITATIONS: Observational study and cohort limited to a sample of patients believed to be potential candidates for PD catheter insertion. CONCLUSION: A history of prior abdominal procedure(s) does not appear to influence catheter outcomes following PD catheter insertion. Such a history should not be a contraindication to PD. PLAIN-LANGUAGE SUMMARY: Peritoneal dialysis (PD) is a life-saving therapy for individuals with kidney failure that can be done at home. PD requires the placement of a tube, or catheter, into the abdomen to allow the exchange of dialysis fluid during treatment. There is concern that individuals who have undergone prior abdominal procedures and are referred for a catheter might have scarring that could affect catheter function. In some institutions, they might not even be offered PD therapy as an option. In this study, we found that a history of prior abdominal procedures did not increase the risk of PD catheter complications and should not dissuade patients from choosing PD or providers from recommending it.

The Association of Intra-Abdominal Adhesions with Peritoneal Dialysis Catheter-Related Complications.

BACKGROUND: This study investigated the association of intra-abdominal adhesions with the risk of peritoneal dialysis (PD) catheter complications. METHODS: Individuals undergoing laparoscopic PD catheter insertion were prospectively enrolled from eight centers in Canada and the United States. Patients were grouped based on the presence of adhesions observed during catheter insertion. The primary outcome was the composite of PD never starting, termination of PD, or the need for an invasive procedure caused by flow restriction or abdominal pain. RESULTS: Seven hundred and fifty-eight individuals were enrolled, of whom 201 (27%) had adhesions during laparoscopic PD catheter insertion. The risk of the primary outcome occurred in 35 (17%) in the adhesion group compared with 58 (10%) in the no adhesion group (adjusted HR, 1.64; 95% confidence interval [CI], 1.05 to 2.55) within 6 months of insertion. Lower abdominal or pelvic adhesions had an adjusted HR of 1.80 (95% CI, 1.09 to 2.98) compared with the no adhesion group. Invasive procedures were required in 26 (13%) and 47 (8%) of the adhesion and no adhesion groups, respectively (unadjusted HR, 1.60: 95% CI, 1.04 to 2.47) within 6 months of insertion. The adjusted odds ratio for adhesions for women was 1.65 (95% CI, 1.12 to 2.41), for body mass index per 5 kg/m 2 was 1.16 (95% CI, 1.003 to 1.34), and for prior abdominal surgery was 8.34 (95% CI, 5.5 to 12.34). Common abnormalities found during invasive procedures included PD catheter tip migration, occlusion of the lumen with fibrin, omental wrapping, adherence to the bowel, and the development of new adhesions. CONCLUSIONS: People with intra-abdominal adhesions undergoing PD catheter insertion were at higher risk for abdominal pain or flow restriction preventing PD from starting, PD termination, or requiring an invasive procedure. However, most patients, with or without adhesions, did not experience complications, and most complications did not lead to the termination of PD therapy.

Establishing a core outcome measure for life participation in patients receiving peritoneal dialysis: A Standardised Outcomes in Nephrology-Peritoneal Dialysis consensus workshop report.

BACKGROUND: Life participation is an outcome of critical importance to patients receiving peritoneal dialysis (PD). However, there is no widely accepted or validated tool for measuring life participation in patients receiving PD. METHODS: Online consensus workshop to identify the essential characteristics of life participation as a core outcome, with the goal of establishing a patient-reported outcome measure for use in all trials in patients receiving PD. Thematic analysis of transcripts was performed. RESULTS: Fifty-six participants, including 17 patients and caregivers, from 15 countries convened via online videoconference. Four themes were identified: reconfiguring expectations of daily living (accepting day-to-day fluctuation as the norm, shifting thresholds of acceptability, preserving gains in flexibility and freedom), ensuring broad applicability and interpretability (establishing cross-cultural relevance, incorporating valued activities, distinguishing unmodifiable barriers to life participation), capturing transitions between modalities and how they affect life participation (responsive to trajectory towards stable, reflecting changes with dialysis transitions) and maximising feasibility of implementation (reducing completion burden, administrable with ease and flexibility). CONCLUSIONS: There is a need for a validated, generalisable outcome measure for life participation in patients receiving PD. Feasibility, including length of time to complete and flexible mode of delivery, are important to allow implementation in all trials that include patients receiving PD.

Digital Applications Targeting Medication Safety in Ambulatory High-Risk CKD Patients: Randomized Controlled Clinical Trial.

BACKGROUND AND OBJECTIVES: Patients with CKD are at risk for adverse drug reactions, but effective community-based preventive programs remain elusive. In this study, we compared the effectiveness of two digital applications designed to improve outpatient medication safety. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In a 1-year randomized controlled trial, 182 outpatients with advanced CKD were randomly assigned to receive a smartphone preloaded with either eKidneyCare (n=89) or MyMedRec (n=93). The experimental intervention, eKidneyCare, includes a medication feature that prompted patients to review medications monthly and report changes, additions, or medication problems to clinicians for reconciliation and early intervention. The active comparator was MyMedRec, a commercially available, standalone application for storing medication and other health information that can be shared with patients' providers. The primary outcome was the rate of medication discrepancy, defined as differences between the patient's reported history and the clinic's medication record, at exit. RESULTS: At exit, the eKidneyCare group had fewer total medication discrepancies compared with MyMedRec (median, 0.45; interquartile range, 0.33-0.63 versus 0.67; interquartile range, 0.40-1.00; P=0.001), and the change from baseline was 0.13±0.27 in eKidneyCare and 0.30±0.41 in MyMedRec (P=0.007). eKidneyCare use also reduced the severity of clinically relevant medication discrepancies in all categories, including those with the potential to cause serious harm (estimated rate ratio, 0.40; 95% confidence interval, 0.27 to 0.63). Usage data revealed that 72% of patients randomized to eKidneyCare completed one or more medication reviews per month, whereas only 30% of patients in the MyMedRec group (adjusted for dropouts) kept their medication profile on their phone. CONCLUSIONS: In patients who are high risk and have CKD, eKidneyCare significantly reduced the rate and severity of medication discrepancies, the proximal cause of medication errors, compared with the active comparator. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: www.ClinicalTrials.gov, NCT:02905474.

Longitudinal Changes in the Use of PD Assistance for Patients Maintained on Peritoneal Dialysis.

Background: Home dialysis therapies, such as peritoneal dialysis (PD), offer flexibility and improved well-being, particularly for older individuals. However, a substantial proportion require assistance with personal care and health care-related tasks. We hypothesized that patients and families would require less PD assistance as they became more familiar with PD-related tasks. The study objective was to assess whether the nature of, and need for, PD assistance decreased over time. Methods: Using a multicentered, prospective, observational study design, patients aged ≥50 years were recruited from those starting PD. Patients underwent formal evaluation using validated components of a Comprehensive Geriatric Assessment at baseline, and they were followed monthly and administered a questionnaire about the need for assistance with PD-related tasks. Results: A total of 111 patients (age 69±10 years, 68% men, and 56% diabetic) were followed for a total of 609 patient-months. Of those who needed help, 40% had help from a family member, and 33% were helped by nurses. Both the quantity and nature of help received by patients remained generally stable throughout follow-up and did not vary according to age, frailty, functional dependence, or cognitive impairment (P=0.93). The proportion of patients needing help varied widely across the 13 different tasks but appeared relatively stable across time. The paid-unpaid caregiver ratio for the different tasks did not change over time. Conclusions: Older patients initiating PD in the outpatient setting have a high need for assistance with PD-related tasks, which seems to persist over the initial 6-month period.

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.

Validation of a Core Patient-Reported Outcome Measure for Fatigue in Patients Receiving Hemodialysis: The SONG-HD Fatigue Instrument.

BACKGROUND AND OBJECTIVES: Fatigue is a very common and debilitating symptom and identified by patients as a critically important core outcome to be included in all trials involving patients receiving hemodialysis. A valid, standardized measure for fatigue is needed to yield meaningful and relevant evidence about this outcome. This study validated a core patient-reported outcome measure for fatigue in hemodialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A longitudinal cohort study was conducted to assess the validity and reliability of a new fatigue measure (Standardized Outcomes in Nephrology-Hemodialysis Fatigue [SONG-HD Fatigue]). Eligible and consenting patients completed the measure at three time points: baseline, a week later, and 12 days following the second time point. Cronbach α and intraclass correlation coefficient were calculated to assess internal consistency, and Spearman rho was used to assess convergent validity. Confirmatory factor analysis was also conducted. Hemodialysis units in the United Kingdom, Australia, and Romania participated in this study. Adult patients aged 18 years and over who were English speaking and receiving maintenance hemodialysis were eligible to participate. Standardized Outcomes in Nephrology-Hemodialysis, the Visual Analog Scale for fatigue, the 12-Item Short Form Survey, and Functional Assessment of Chronic Illness Therapy-Fatigue were used. RESULTS: In total, 485 participants completed the study across the United Kingdom, Australia, and Romania. Psychometric assessment demonstrated that Standardized Outcomes in Nephrology-Hemodialysis is internally consistent (Cronbach α =0.81-0.86) and stable over a 1-week period (intraclass correlation coefficient =0.68-0.74). The measure demonstrated convergence with Functional Assessment of Chronic Illness Therapy-Fatigue and had moderate correlations with other measures that assessed related but not the same concept (the 12-Item Short Form Survey and the Visual Analog Scale). Confirmatory factor analysis supported the one-factor model. CONCLUSIONS: SONG-HD Fatigue seems to be a reliable and valid measure to be used in trials involving patients receiving hemodialysis.

International variation in dialysis discontinuation in patients with advanced kidney disease.

BACKGROUND: Decisions about dialysis for advanced kidney disease are often strongly shaped by sociocultural and system-level factors rather than the priorities and values of individual patients. We examined international variation in the uptake of conservative approaches to the care of patients with advanced kidney disease, in particular discontinuation of dialysis. METHODS: We employed an observational cohort study design using data collected from patients maintained on long-term hemodialysis between 1996 and 2015 in facilities across 12 developed countries participating in the Dialysis Outcomes and Practice Patterns Study (DOPPS). The main outcome was discontinuation of dialysis therapy. We analyzed the association between several patient characteristics and time to dialysis discontinuation by country and phase of study entry. RESULTS: A total of 259 343 DOPPS patients contributed data to the study, of whom 48 519 (18.7%) died during the study period. Of the decedents, 5808 (12.0%) discontinued dialysis before death. Rates of discontinuation were higher within the first few months after initiation of dialysis, among older adults, among those with a greater number of comorbidities and among those living in an institution. After adjustment for age, sex, dialysis duration, diabetes and dialysis era, rates of discontinuation were highest in Canada, the United States and Australia/New Zealand (33.8, 31.4 and 21.5 per 1000/yr, respectively) and lowest in Japan and Italy (< 0.1 per 1000/yr). Crude discontinuation rates were highest in dialysis facilities that were more likely to offer comprehensive conservative renal care to older adults. INTERPRETATION: We found persistent international variation in average rates of dialysis discontinuation not explained by differences in patient case-mix. These differences may reflect physician-, facility- and society-level differences in clinical practice. There may be opportunities for international cross-collaboration to improve support for patients with end-stage renal disease who prefer a more conservative approach.

A Proof-of-Concept Investigation of an Energy Management Education Program to Improve Fatigue and Life Participation in Adults on Chronic Dialysis.

BACKGROUND: Fatigue and its negative impact on life participation are top research priorities of people on chronic dialysis therapy. Energy management education (EME) is a fatigue management approach that teaches people to use practical strategies (eg, prioritizing, using efficient body postures, organizing home environments) to manage their energy expenditure during everyday life. OBJECTIVE: The aim of this study is to explore whether EME is associated with improvements in fatigue and life participation in adults on chronic dialysis. DESIGN: Five single-case interrupted time-series AB studies, and follow-up qualitative interviews. SETTING: The hemodialysis and peritoneal dialysis units at an academic hospital in Toronto, Canada. PATIENTS: In total, 5 patients on chronic dialysis therapy were purposively selected to represent diversity in age, gender, and modality. MEASUREMENTS: Brief questionnaires assessing fatigue and life participation were administered weekly during the baseline and intervention periods. Additional validated questionnaires (the Fatigue Impact Scale, 36-Item Short-Form Health Survey [SF-36] Vitality Scale, and Canadian Occupational Performance Measure) were also administered at baseline and post-intervention. METHODS: All participants underwent "The PEP Program," a personalized, web-supported EME program designed to meet the needs of people on dialysis. During the program, participants complete 2 brief web modules about energy management, and then use energy management principles and a problem-solving framework to work on 3 life participation goals during sessions with a trained program administrator. Data were analyzed using visual analysis and the Tau-U statistic for the weekly time-series data, and thematic analysis for the qualitative interviews. RESULTS: Three of 5 participants displayed a consistently positive response to the Personal Energy Planning (PEP) program across multiple measures of fatigue and life participation. Tau-U effect size estimates ranged from small to moderate, according to the time-series data. All 5 participants expressed that the program had benefited them in qualitative follow-up interviews, with the most common reported benefit being that the program made day-to-day activities easier. The format of the program was also said to be feasible and convenient. LIMITATIONS: An exploratory, proof-of-concept study that used a small set of participants and lacked an active control comparison. CONCLUSIONS: The PEP program might have potential for improving fatigue-related outcomes in people on chronic dialysis. Larger, controlled studies of the program are warranted.

CONTEXTE: La fatigue et les effets négatifs qu'elle entraîne sur la participation à la vie constituent les principales priorités de recherche des personnes suivant un traitement de dialyse chronique. L'éducation à l'économie d'énergie, qui sensibilise les patients à des stratégies concrètes (priorisation, adoption de postures plus ergonomiques, organisation de l'environnement de vie) pour réduire leurs dépenses énergétiques au quotidien, est l'approche préconisée pour gérer la fatigue. OBJECTIF: Examiner l'association entre la sensibilisation à une bonne gestion de l'énergie et une amélioration de la fatigue et de la participation à la vie chez des adultes suivant des traitements de dialyse chronique. TYPE D'ÉTUDE: Cinq études chronologiques interrompues de type AB à cas unique, et entretiens de suivi qualitatif. CADRE: Les unités d'hémodialyse et de dialyse péritonéale d'un hôpital universitaire de Toronto (Canada). SUJETS: Des patients (n = 5) suivant des traitements de dialyse chronique sélectionnés à dessein pour être représentatifs de la diversité d'âges, de genres et de modalités. MESURES: Pendant la phase initiale et la période d'intervention, de courts questionnaires évaluant la fatigue et la participation à la vie, de même que des questionnaires validés supplémentaires (Fatigue Impact Scale, SF-36 Vitality Scale et Mesure canadienne du rendement occupationnel), ont été soumis chaque semaine aux patients. MÉTHODOLOGIE: Tous les participants ont suivi le « Programme d'éducation prédialyse ¼ (PEP), un programme en ligne d'éducation à la bonne gestion de l'énergie, adapté aux besoins des patients dialysés. Au cours du programme, les participants devaient compléter deux courts modules, puis intégrer les principes de gestion de l'énergie et un cadre de résolution de problèmes afin de travailler sur trois objectifs de participation à la vie au cours de séances avec un administrateur de programme formé. Les données ont été traitées avec l'analyse visuelle. La statistique Tau-U a été employée pour les séries hebdomadaires de données chronologiques et une analyse thématique pour les entretiens qualitatifs. RÉSULTATS: Trois des cinq participants ont réagi de façon positive et constante au PEP pour différentes mesures de fatigue et de participation à la vie. Selon les données des séries chronologiques, les estimations de la taille de l'effet Tau-U variaient de faible à modérée. Lors des entretiens de suivi qualificatif, tous les participants ont mentionné que le programme leur avait été bénéfique; le bienfait le plus souvent cité étant que celui-ci avait facilité leurs activités quotidiennes. Les participants ont également jugé le format du programme pratique et réalisable. LIMITES: Il s'agit d'une étude exploratoire visant une preuve de concept dont l'échantillon est faible et n'a pas fait l'objet d'une comparaison avec un contrôle actif. CONCLUSION: Le programme d'éducation prédialyse a le potentiel d'améliorer la qualité de vie des personnes sous dialyse chronique en les aidant à mieux gérer la fatigue. L'évaluation du programme requiert des études contrôlées de plus grande envergure.

Identifying dimensions of fatigue in haemodialysis important to patients, caregivers and health professionals: An international survey.

BACKGROUND: Patient-reported outcome measures of fatigue used in research in haemodialysis vary widely in the dimensions assessed; and the importance of these dimensions to patients and health professionals is unknown. This study aimed to identify the most important dimensions of fatigue to assess in patients on haemodialysis participating in trials. METHODS: In an international survey, patients/caregivers and health professionals rated the absolute and relative importance of content and measurement dimensions to include in a core outcome measure of fatigue. A 9-point Likert scale (7-9 indicating critical importance) was used to assess absolute importance and best-worst scale was used to assess importance of each dimension compared to others. RESULTS: In total, 169 patients/caregivers and 336 health professionals from 60 countries completed the survey. Both groups (patients/caregivers and health professionals) rated life participation (7.55), tiredness (7.40), level of energy (7.37), ability to think clearly (7.15), post-dialysis fatigue (7.13), motivation (7.03) and ability to concentrate (7.03) as critically important (mean Likert score greater than 7) content dimensions to include in a core outcome measure. Compared to patients and caregivers, health professionals rated post-dialysis fatigue, memory and verbal abilities more highly. Based on the relative importance scores, life participation was ranked most highly above all content dimensions. Severity was rated and ranked the most important measurement dimension by all stakeholders. CONCLUSION: A core outcome measure of fatigue should assess impact of fatigue on life participation, tiredness and level of energy, using a severity scale. A consistent and valid measurement of fatigue will improve the value of trials in supporting decision-making based on this important outcome.

PD Assistance and Relationship to Co-Existing Geriatric Syndromes in Incident Peritoneal Dialysis Therapy Patients.

Background:Home dialysis therapies, including peritoneal dialysis (PD), are preferred treatment strategies, offering flexibility and improved wellbeing. However, patients with complex disease and comorbidity may require assistance with personal care and healthcare-related tasks. The study objective was to formally assess the type and frequency of PD assistance received by patients over 50, and the relationship to observed frailty, functional status, and cognitive ability at the time of PD therapy initiation.Methods:Using a multicentered, prospective observational study design, patients aged ≥ 50 years were recruited from those starting PD. Patients underwent formal evaluation using validated components of a Comprehensive Geriatric Assessment. The receipt and nature of assistance with PD tasks were assessed 1 month after dialysis start by questionnaire.Results:A total of 121 patients (age 69 ± 10 years, 67% male, 54% diabetic) were recruited. A total of 75 (62%) patients received assistance for a variety of tasks from friends or family (n = 41, 34%) or a paid caregiver (n = 34, 28%) 1 month after starting dialysis. At baseline, there was a high prevalence of functional dependency (79/120, 66%), frailty (71/110, 65%), and impaired cognition (68/115, 59%). Only 5% were fully independent, clinically robust, and scored within the normal range on cognitive testing. Factors associated with PD assistance included comorbidity (p < 0.03), cognitive impairment (p < 0.0001), and functional dependence (p < 0.02).Conclusion:Older patients initiating PD in the outpatient setting have high rates of frailty, functional dependence, and cognitive changes at the time they initiate dialysis. More research is required to better understand how those factors contribute to the use of PD assistance.

Pharmacokinetic Study of Cefazolin in Short Daily Hemodialysis.

BACKGROUND: A number of centers across the world offer short daily hemodialysis (SDHD) treatments. To date, cefazolin pharmacokinetics have not been described in patients undergoing SDHD. OBJECTIVE: The purpose of this study was to investigate the effect of SDHD on the pharmacokinetics of cefazolin. METHODS: This was a prospective, open-label, pharmacokinetic study of cefazolin during SDHD in 10 noninfected patients. Participants received a 1-g intravenous (IV) infusion of cefazolin after SDHD on study day 1 and a second dose after SDHD on study day 2. To determine the concentration of cefazolin, 6 blood samples were drawn at 0, 1, 2, 2.3, 4, and 24 hours after initiation of dialysis on day 2, and 2 dialysate samples were drawn at 1 and 2 hours after initiation of dialysis on day 2. Samples were analyzed using high-performance liquid chromatography, and pharmacokinetic parameters were determined. RESULTS: Median interdialysis clearance was 0.16 L/h (interquartile range [IQR]: 0.11-0.21 L/h), and median intradialysis clearance was 1.95 L/h (IQR: 1.66-2.45 L/h). Median interdialysis half-life was 28.2 hours (IQR: 23.5-59.3 hours) as compared with a median intradialysis half-life of 2.3 hours (IQR: 1.7-2.7 hours). The median percentage removal of cefazolin during dialysis was 41% (IQR: 35%-53%). Conclusion and Relevance: Estimated cefazolin dialysis clearance is similar to previous estimates with conventional thrice-weekly regimens. Current dosing recommendations of 1 g IV post-SDHD achieve total serum drug concentrations greater than 40 mg/L in all patients, which is the total drug concentration required for bactericidal activity against Staphylococcus species.

A Longitudinal Study Examining the Change in Functional Independence Over Time in Elderly Individuals With a Functioning Kidney Transplant.

BACKGROUND: Functional disability is defined as the need for assistance with self-care tasks. OBJECTIVE: To document changes in functional status over time among older prevalent renal transplant recipients. DESIGN: Single center, prospective, follow-up study. SETTING: Single center, tertiary care transplant center. PATIENTS: Patients, with a functioning kidney transplant, aged 65 years or older who underwent assessment of functional status approximately 12 months previously. MEASUREMENTS: Validated tools used included Barthel Index, the Lawton-Brody Scale of Instrumental Activities of Daily Living, the Timed Up and Go test, the Veterans Specific Activity Questionnaire, the Mini-Cog, and dynamometer handgrip strength. METHODS: Outpatient assessment by a trained observer. RESULTS: Of the 82 patients previously studied, 64 (78%) patients participated in the follow-up study (mean age 70.5 ± 4.4 years, 58% male, 55% diabetic). Among those completing functional status measures, 32 (50%) had functional disability at baseline. Over the 1-year period, 11 (17%) of these patients experienced progressive functional decline, 6 (9%) exhibited no change, and 15 (23%) had functional recovery. Eleven patients (17%) initially independent, developed new-onset disability. One of the strongest predictors of progressive functional decline was having 1 or more falls in the previous year. LIMITATIONS: Assessments were performed only on 2 occasions separated by approximately 1 year. CONCLUSIONS: Fluctuations in disability states are common among older adults living with renal transplants. Episodes of functional disability may place individuals at higher risk of persistent and/or progressive disability.

CONTEXTE: La déficience fonctionnelle se définit comme le besoin pour une personne d'être assistée dans ses activités et soins quotidiens. OBJECTIFS DE L'ÉTUDE: L'étude visait à documenter les variations dans l'état fonctionnel qui se constatent au fil du temps chez les personnes âgées receveuses d'une greffe rénale. TYPE ET CADRE DE L'ÉTUDE: Il s'agit d'une étude de suivi prospective qui s'est tenue dans un seul centre de soins tertiaires en transplantation. PARTICIPANTS: Une cohorte de patients âgés de 65 ans et plus ayant reçu une greffe rénale et dont l'évaluation de l'état fonctionnel avait été faite dans les 12 mois précédant l'intervention. MESURES: Les outils validés suivants ont servi à colliger les données : l'indice Barthel, l'échelle d'activités instrumentales de la vie courante de Lawton (IDAL - Lawton-Brody Scale of Instrumental Activities of Daily Living), le test chronométré du lever de chaise (timed up and go test), le Veterans Specific Activity Questionnaire, le test Mini-Cog et le test de force de préhension au dynamomètre. MÉTHODOLOGIE: L'évaluation des patients externes a été effectuée par un observateur formé à cet effet. RÉSULTATS: Des 82 patients étudiés précédemment, 64 (78 %) ont participé à l'étude de suivi; leur âge moyen était de 70,5 ± 4,4 ans, 58 % étaient des hommes et 55 % souffraient de diabète. Parmi les patients qui ont complété les mesures de l'état fonctionnel, 32 (50 %) présentaient des déficiences fonctionnelles au départ. Au cours de l'année, 11 (17 %) patients ont vu leur état fonctionnel décliner progressivement, 6 (9 %) n'ont connu aucun changement de leur état et 15 (23 %) ont vu leur capacité fonctionnelle rétablie. Par ailleurs, au cours de la même période, on a constaté l'apparition d'une nouvelle incapacité pour onze patients (17 %) considérés au départ comme indépendants. On a observé que le fait d'avoir chuté une ou plusieurs fois au cours de l'année précédente s'avérait l'un des meilleurs facteurs prédictifs d'un déclin fonctionnel progressif. LIMITES DE L'ÉTUDE: L'évaluation des patients n'a été réalisée qu'à deux reprises, et celles-ci étaient séparées d'une période d'environ un an. CONCLUSION: Les variations de l'état fonctionnel sont fréquentes chez les personnes âgées ayant subi une transplantation rénale. Les épisodes d'incapacité fonctionnelle sont susceptibles d'exposer le patient à un plus grand risque de déclin fonctionnel persistant ou progressif.

Establishing a Core Outcome Measure for Fatigue in Patients on Hemodialysis: A Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) Consensus Workshop Report.

Fatigue is one of the most highly prioritized outcomes for patients and clinicians, but remains infrequently and inconsistently reported across trials in hemodialysis. We convened an international Standardized Outcomes in Nephrology-Hemodialysis (SONG-HD) consensus workshop with stakeholders to discuss the development and implementation of a core outcome measure for fatigue. 15 patients/caregivers and 42 health professionals (clinicians, researchers, policy makers, and industry representatives) from 9 countries participated in breakout discussions. Transcripts were analyzed thematically. 4 themes for a core outcome measure emerged. Drawing attention to a distinct and all-encompassing symptom was explicitly recognizing fatigue as a multifaceted symptom unique to hemodialysis. Emphasizing the pervasive impact of fatigue on life participation justified the focus on how fatigue severely impaired the patient's ability to do usual activities. Ensuring relevance and accuracy in measuring fatigue would facilitate shared decision making about treatment. Minimizing burden of administration meant avoiding the cognitive burden, additional time, and resources required to use the measure. A core outcome measure that is simple, is short, and includes a focus on the severity of the impact of fatigue on life participation may facilitate consistent and meaningful measurement of fatigue in all trials to inform decision making and care of patients receiving hemodialysis.

The Relationship Between Fatigue and Depression in Adults With End-Stage Renal Disease on Chronic In-Hospital Hemodialysis: A Scoping Review.

CONTEXT: Fatigue and depression are two prominent concerns in patients on in-hospital hemodialysis (IHHD) that have recently been identified as research priorities in the nephrology community. Although they are often reported to co-exist, no synthesis of the literature examining their relationship is available. OBJECTIVE: The aim of this study was to characterize the literature on the relationship between fatigue and depression in IHHD patients. METHODS: A scoping review as described by Arksey and O'Malley was conducted. Seven electronic databases were searched for relevant literature using search terms pertaining to fatigue, depression, and IHHD. Key journals and article reference lists were also hand searched to identify relevant literature. Articles were examined for relevance, and data were extracted to describe the nature and scope of the literature and to characterize the relationship between fatigue and depression. Findings were grouped thematically and summarized descriptively. RESULTS AND CONCLUSIONS: Current literature on this topic is dominated by cross-sectional studies, which support the existence of an association between fatigue and depression in IHHD patients in various practice settings and subpopulations. Numerous multivariable analyses have been performed which suggest the association remains after adjustment for confounding factors. However, there is generally a dearth of longitudinal or interventional literature to clarify the nature of the relationship over time. Current literature is sufficient to justify routine screening for depression in IHHD patients who present with fatigue. Future research should aim to clarify the nature of the relationship over time in IHHD patients, explore mediators and modifiers of the relationship, and investigate the effects of interventions.

Integrating a Smartphone-Based Self-Management System into Usual Care of Advanced CKD.

BACKGROUND AND OBJECTIVES: Patient self-management has been shown to improve health outcomes. We developed a smartphone-based system to boost self-care by patients with CKD and integrated its use into usual CKD care. We determined its acceptability and examined changes in several clinical parameters. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We recruited patients with stage 4 or 5 CKD attending outpatient renal clinics who responded to a general information newsletter about this 6-month proof-of-principle study. The smartphone application targeted four behavioral elements: monitoring BP, medication management, symptom assessment, and tracking laboratory results. Prebuilt customizable algorithms provided real-time personalized patient feedback and alerts to providers when predefined treatment thresholds were crossed or critical changes occurred. Those who died or started RRT within the first 2 months were replaced. Only participants followed for 6 months after recruitment were included in assessing changes in clinical measures. RESULTS: In total, 47 patients (26 men; mean age =59 years old; 33% were ≥65 years old) were enrolled; 60% had never used a smartphone. User adherence was high (>80% performed ≥80% of recommended assessments) and sustained. The mean reductions in home BP readings between baseline and exit were statistically significant (systolic BP, -3.4 mmHg; 95% confidence interval, -5.0 to -1.8 and diastolic BP, -2.1 mmHg; 95% confidence interval, -2.9 to -1.2); 27% with normal clinic BP readings had newly identified masked hypertension. One hundred twenty-seven medication discrepancies were identified; 59% were medication errors that required an intervention to prevent harm. In exit interviews, patients indicated feeling more confident and in control of their condition; clinicians perceived patients to be better informed and more engaged. CONCLUSIONS: Integrating a smartphone-based self-management system into usual care of patients with advanced CKD proved feasible and acceptable, and it appeared to be clinically useful. The results provide a strong rationale for a randomized, controlled trial.

Equivalent Fall Risk in Elderly Patients on Hemodialysis and Peritoneal Dialysis.

UNLABELLED: ♦ BACKGROUND: Accidental falls are common in the hemodialysis (HD) population. The high fall rate has been attributed to a combination of aging, kidney disease-related morbidity, and HD treatment-related hazards. We hypothesized that patients maintained on peritoneal dialysis (PD) would have fewer falls than those on chronic HD. The objective of this study was to compare the falls risk between cohorts of elderly patients maintained on HD and PD, using prospective data from a large academic dialysis facility. ♦ METHODS: Patients aged 65 years or over on chronic in-hospital HD and PD at the University Health Network were recruited. Patients were followed biweekly, and falls occurring within the first year recorded. Fall risk between the 2 groups was compared using both crude and adjusted Poisson lognormal random effects modeling. ♦ RESULTS: Out of 258 potential patients, 236 were recruited, assessed at baseline, and followed biweekly for falls. Of 74 PD patients, 40 (54%) experienced 86 falls while 76 out of 162 (47%) HD patients experienced a total of 305 falls (crude fall rate 1.25 vs 1.60 respectively, odds ratio [OR] falls in PD patients 0.78, 95% confidence interval [CI] 0.61 - 0.92, p = 0.04). After adjustment for differences in comorbidity, number of medications, and other demographic differences, PD patients were no less likely to experience accidental falls than HD patients (OR 1.63, 95% CI 0.88 - 3.04, p = 0.1). ♦ CONCLUSIONS: We conclude that accidental falls are equally common in the PD population and the HD population. These data argue against post-HD hypotension as the sole contributor to the high fall risk in the dialysis population.

Development, validation, and implementation of a medication adherence survey to seek a better understanding of the hemodialysis patient.

BACKGROUND: Factors contributing to non-adherence have become a priority for clinicians, healthcare policy makers, and healthcare payers alike. Patients who are non-adherent to their medication regimen appear to have poor health outcomes, with evidence of both high mortality rates and high morbidity in the form of more frequent emergency room admissions, recurrent exacerbations of disease, and poor overall well-being. The primary objective of this study was to identify and describe patient-identified factors associated with non-adherence in patients maintained on chronic hemodialysis. METHODS: A 23-item questionnaire was developed and validated for use in the hemodialysis population. This questionnaire was administered to patients undergoing chronic hemodialysis in a single center during the period of October to December 2013. RESULTS: A total of 156/183 eligible patients consented. Of these 156 patients, 36 (23%) patients reported being non-adherent. The most common non-adherent behaviors were changing the frequency of taking medications and skipping doses. Patients identified information gaps around medication interactions, the flexibility around drug timings, and how best to manage medications that needed to be taken apart from, with, or without food. CONCLUSIONS: Our study shows that, despite an intensive drug education program, almost one quarter of patients continue to have problems with taking medication and that traditional education around medications is insufficient. We propose that clinicians customize education to the patient-driven gaps in knowledge, in particular focusing on the education needed to empower patients to recognize which aspects of their care they can and should modify and which aspects require further clinician input.

Functional Disability in Older Adults Maintained on Peritoneal Dialysis Therapy.

UNLABELLED: ♦ BACKGROUND: Older in-center hemodialysis patients have a high burden of functional disability. However, little is known about patients on home chronic peritoneal dialysis (PD). As patients opting for home dialysis are expected to play a greater role in their own dialysis care, we hypothesized that a relatively low number of PD patients would require help with basic self-care tasks (ADL) and instrumental activities of daily living (IADL). ♦ METHODS: We used a cross-sectional study design to measure the proportion of patients aged 65 years and older undergoing outpatient PD who needed help with day-to-day activities. Patients living in nursing homes were excluded from the study. Functional dependence in ADL and IADL tasks were measured by the Barthel and Lawton Scales. Physical performance measures used included the timed up-and-go (TUG) test, chair stands and Folstein mini-mental score (MMSE). ♦ RESULTS: A total of 74 of 76 (97%) eligible PD patients participated. Patients had a mean age of 76.2 ± 7.5 years. Thirty-six percent had impaired MMSE scores, 69% were unable to stand from a chair without the use of their arms and 51% had abnormal TUG scores. Only 8 patients (11%) were fully independent for both ADL and IADL activities. Dependence in one or more ADL activity was reported by 64% of participants, while 89% reported dependence in one or more IADL. ♦ CONCLUSIONS: Impaired physical and functional performance is common in older patients maintained on PD. Collaborative geriatric-renal programs may be beneficial within the dialysis community.