Intradialytic cycling does not exacerbate microparticles or circulating markers of systemic inflammation in haemodialysis patients.

PURPOSE: Patients receiving haemodialysis (HD) display elevated circulating microparticle (MP) concentration, tissue factor (TF) expression and markers of systemic inflammation, though regular intradialytic cycling (IDC) may have a therapeutic effect. This study investigated the impact of regular, moderate-intensity IDC on circulating MPs and inflammatory markers in unit-based HD patients. METHODS: Patients were cluster-randomised to intervention (n = 20, age: 51.4 ± 18.1 years, body mass: 77.6 ± 18.3 kg, mean ± SD) or no-exercise control (n = 20, 56.8 ± 14.0 years, 80.5 ± 26.5 kg). Intervention participants completed 30 min of moderate intensity (rating of perceived exertion [RPE] of 12-14) IDC, thrice weekly for 6 months. Pre-dialysis venous blood samples were obtained at 0, 3 and 6 months. Circulating MP phenotypes, cytokines, chemokine and MP TF expression were quantified using flow cytometry and cytometric bead array assays. RESULTS: Despite high exercise compliance (82%), no IDC-dependent effects were observed for any MP, cytokine or chemokine measure (p ≥ 0.051, ηρ2 ≤ 0.399) other than TNF-α (p = 0.001, ηρ2 = 0.186), though no significance was revealed upon post hoc analysis. CONCLUSION: Six months of regular, moderate-intensity IDC had no effect on MPs, cytokines or chemokines. This suggests that the exercise did not exacerbate thrombotic or inflammatory status, though further functional assays are required to confirm this. TRIAL REGISTRATION: ISRCTN1129707, prospectively registered on 05/03/2015.

Effects of intradialytic exercise for advanced-age patients undergoing hemodialysis: A randomized controlled trial.

Previous reports have shown the benefits of intradialytic exercise to patients undergoing hemodialysis. However, most of those studies assessed the effects of exercise in middle-aged patients and little is known about advanced-age patients undergoing hemodialysis. Therefore, the present randomized controlled trial was performed to determine the effectiveness of exercise therapy in advanced-age patients undergoing hemodialysis. This non-blinded, randomized controlled parallel trial enrolled a total of 101 patients who were randomly assigned to intradialytic exercise (n = 51) or usual care (n = 50) groups. The training program included both resistance and aerobic exercises and was performed three times per week for 6 months. The aerobic exercise intensity was adjusted to a target Borg score of 13 for 20 minutes. Four types of resistance exercises were performed using elastic tubing, with three sets of 10 exercises performed at moderate intensity (13/20 on the Borg scale). The usual care group received standard care. Lower extremity muscle strength, Short Physical Performance Battery score, and 10-m walking speed were the outcomes and were evaluated before the hemodialysis session and after 6 months of training. There were statistically significant improvements in Short Physical Performance Battery score (effect size, 0.57; 95% confidence interval, 0.15‒1.95) in the exercise group relative to the control group. There were no statistically significant differences in lower extremity muscle strength or in the 10-m walking speed between the two groups. These findings suggest that 6 months of intradialytic training could improve physical function in older patients undergoing hemodialysis.

Intradialytic exercise in end-stage renal disease: An umbrella review of systematic reviews and/or meta-analytical studies.

OBJECTIVES: This umbrella review aimed to understand the clinical benefits and adverse events associated with different modalities of intradialytic exercise in patients with end-stage renal disease undergoing hemodialysis. DATA SOURCES: The search was performed until September 10th, 2020 on Scopus, Web of Science, the Cochrane Database, CINAHL, and PubMed. METHODS: This umbrella review was conducted following the PRISMA guideline statement. The methodological quality of the reviews was assessed with the AMSTAR-2. Standardized mean differences with 95% confidence intervals were estimated. The I-squared statistic was used to assess heterogeneity and the Eggers' test was performed to test asymmetry/small-study effects. RESULTS: Eleven reviews were included and 48 unique meta-analyses were examined. Nine were supported by suggestive evidence (P < 0.05, small heterogeneity, absence of small-study effects, and excess significance bias). Clinical benefits were found for functional capacity associated with aerobic exercise (d = 0.81; k = 6), resistance training (d = 0.58; k = 6), neuromuscular electrical stimulation (d = 0.70; k = 5), and inspiratory muscle training (d = 1.13; k = 2), measured by the distance covered in the 6-minutes walking test. This outcome was also associated with aerobic exercise (d = 0.28; k = 7) and combined exercise, measured by VO2peak (d = 1.01; k = 5) and by the duration of the cardiopulmonary test (d = 1.07; k = 4). Isometric quadriceps muscle strength improved with neuromuscular electrical stimulation (d = 1.19; k = 7) while patients' perception of vitality improved with combined exercise (d = 0.60; k = 3). CONCLUSIONS: Suggestive evidence was found for the associations between various modalities of intradialytic exercise and functional capacity. Combined exercise was associated with improvements in physical and psychosocial variables. Few or no adverse events were reported.

Interventions Made to Preserve Cognitive Function Trial (IMPCT) study protocol: a multi-dialysis center 2x2 factorial randomized controlled trial of intradialytic cognitive and exercise training to preserve cognitive function.

BACKGROUND: Kidney disease and dialysis significantly impact cognitive function across the age spectrum. Cognitive training (CT) and/or exercise training (ET) are promising approaches to preserve cognitive function among community-dwelling older adults, but have not been tested for cognition preservation in hemodialysis patients of all ages. In this manuscript, we summarize the protocol for the Interventions Made to Preserve Cognitive Function Trial (IMPCT). METHODS: We will perform a 2 × 2 factorial randomized controlled trial (RCT) of eligible adult (≥18 years) hemodialysis initiates (n = 200) to test whether intradialytic CT (brain games on a tablet PC), ET (foot peddlers) and combined CT + ET while undergoing hemodialysis preserves executive function compared to standard of care (SC). Participants will engage in the interventions to which they are randomized for 6 months. The primary objective is to compare, among interventions, the 3-month change in executive function measured using the Trail Making Test A (TMTA) and B (TMTB); specifically, executive function is calculated as TMTB-TMTA to account for psychomotor speed. This primary outcome was selected based on findings from our pilot study. The secondary objectives are to compare the risk of secondary cognitive outcomes, ESKD-specific clinical outcomes, and patient-centered outcomes at 3-months and 6-months. All data collection and interventions are conducted in the dialysis center. DISCUSSION: We hypothesize that receiving intradialytic CT or ET will better preserve executive function than SC but receiving combined CT + ET, will be the most effective intervention. The current trial will be an important step in understanding how intradialytic interventions might preserve cognitive health. TRIAL REGISTRATION: Clinicaltrials.Gov (Date: 8/6/18): # NCT03616535 . Protocol Version: 10 (April 2020). FUNDING: NIDDK R01DK114074.

Hypnosis and end-stage renal disease: Review and treatment.

ABSRACT End-stage renal disease is an irreversible, fatal, condition. There are two treatments that extend life, dialysis, and transplant. Both are accompanied by recognized consequences. Although the emotional impacts are extensive, and the symptoms are treatable, there have been very few reports of their amelioration by hypnosis. This article summarizes what research has been done and proposes a manual for self-care to meet this worldwide and growing clinical challenge.

Exercise Training and Outcomes in Hemodialysis Patients: Systematic Review and Meta-Analysis.

BACKGROUND: Inadequate dialysis, renal hypertension, and impaired exercise capacity are factors that affect the quality of life (QoL) and mortality of adults with end-stage renal disease (ESRD) undergoing hemodialysis (HD). This systematic review provided valid evidence about the effect of exercise training on single-pool Kt/V (sp Kt/V), blood pressure, and peak uptake oxygen (VO2 peak). METHOD: A systematic review and meta-analysis of published randomized controlled trials (RCTs) that evaluated the effects of no <8 weeks' exercise training on the physical fitness outcomes for adults with ESRD undergoing HD were accepted in this study. RESULTS: Included 20 trials (677 participants) indicated that various exercise types improved aerobic capacity, walking capacity, and health-related QoL totally. Of note, aerobic exercise and combined exercise were the predominant exercise types. CONCLUSION: Based on our evidence, aerobic exercise or combined exercise at least for 8 weeks to 12 months, 3 times weekly, will be beneficial to physical conditions of the patients with ESRD undergoing HD. The clinical staff can treat patients with the evidence above. Future studies need to provide more information basis for the construction of patient exercise system by adding various exercise combinations.

Attitudes of hemodialysis patients, medical and nursing staff towards patients' physical activity.

PURPOSE: Patients with end-stage renal disease (ESRD) seem to have a negative attitude towards physical activity, which is mainly favored by the lack of counseling provided by the medical and nursing staff. The aim of this study was to investigate the attitudes of both ESRD patients and medical staff on the participation and promotion of physical activity and identify the obstacles that discourage patients' involvement in intervention programs. STUDY DESIGN: Subjective assessment questionnaires and the International Physical Activity Questionnaire were administrated to hemodialysis patients and medical staff, to investigate the association between patient's barriers to physical activity, the total intensity level of physical activity, and attitudes of both ESRD patients and medical staff on the participation and promotion of physical activity. RESULTS: A total of 103 ESRD patients (61 men, 59.2%), 20 nephrologists (12 men, 60.0%), and 72 nurses (61 women, 84.7%) participated in the study. Most commonly reported patient's barriers were fatigue on dialysis (97.4%) and non-dialysis days (55.1%). Healthcare staff showed positive attitude towards renal rehabilitation exercise programs. However, most of physicians (85.0%) and nurses (83.3%) did not have previous experience with interventional exercise rehabilitation programs. Binary logistic regression revealed significant association between patients' inactivity, demographic data, and barriers towards physical activity, such as fatigue and pain in dialysis and non-dialysis days (p < 0.05), family's and physician's concern (p < 0.05), too many medical problems (p < 0.05), the fear of getting hurt (p = 0.01), and unwillingness for exercise (p < 0.05). Interestingly, healthcare staff's negative attitudes toward patient's physical activity seem to be strongly associated with patient's inactivity status. CONCLUSION: Healthcare staff negative attitudes and multiple related barriers especially fatigue on dialysis and non-dialysis days, towards ESRD patient's physical activity, suppress desire for exercise and active patients' status, leading them to abstain from it.

Addressing myths about exercise in hemodialysis patients.

Despite decades of research, there are few published guidelines related to the safety and efficacy of exercise training in hemodialysis patients. This has led to disparate recommendations regarding the type, intensity, and timing for exercise, especially for patients with multiple comorbidities. Many common recommendations are not supported by research data, so their justification is uncertain. These recommendations include exercising in the first hour of dialysis; not exercising if hypertensive, cramping, or volume overloaded; avoiding heavy weights on vascular access limb; clinicians managing an exercise program; intradialytic exercise or interdialytic exercise is better; and strength training during dialysis is impractical. The purpose of this review is to describe the evidence that supports or refutes these beliefs. In summary, these beliefs or myths have generally led to an overly conservative approach to exercise that serves as a barrier to increasing physical activity levels in an overly sedentary population that could benefit from moving more.

Maintenance Haemodialysis in the Edward Francis Small Teaching Hospital in the Gambia.

Maintenance haemodialysis is the most common form of renal replacement therapy treatment in Sub-Saharan Africa. In spite of this, there is a general inadequacy for patients receiving this form of therapy due to lack of materials, human resources and funding from the governments. This form of treatment is relatively new in the Gambia compared to many West African countries, but there is also an enormous challenge on the part of the government to ensure that the citizens benefit from this form of therapy. Inadequate finances and human resources are making it difficult for the Gambia government to achieve this objective. It is therefore imperative for the state to invest more efforts on preventive strategies, which until today continue to remain inadequate.

Exercise interventions on patients with end-stage renal disease: a systematic review.

OBJECTIVE:: This study aimed to conduct an up-to-date systematic review of the literature to evaluate the effects of exercise on fatigue, anxiety, depression, physical activity, and quality of life (QOL) in patients with end-stage renal disease. DATA SOURCES:: We searched PubMed (October 2018), Embase (from 1966 to October 2018), Web of Science (from 1900 to October 2018), The Cochrane Library (October 2018), and references of papers. METHODS:: This study includes randomized controlled trials that analyzed the combined effects of exercise intervention on patients with end-stage renal disease. Two reviewers independently screened the retrieved records, extracted data, and assessed the risk of bias for inclusion in the study. The effects of exercise intervention were conducted in the meta-analysis using RevMan 5.3 software. RESULTS:: A total of 614 participants were included in 13 randomized controlled studies. The study revealed that exercise can improve fatigue, anxiety, depression, physical activity, and QOL. The effect value results were as follows: (1) fatigue, -0.97 (95% confidence interval (CI) -1.32 to -0.62, P < 0.00001); (2) anxiety, -0.78 (95% CI -1.17 to -0.39, P < 0.0001); (3) depression, -0.85 (95% CI -1.13 to -0.56, P < 0.00001) (4) physical activity, 38.15 (95% CI 21.20 to 55.10, P < 0.0001); (5) QOL, the physical component of the 36-item Short-Form Health Survey (SF-36), 4.73 (95% CI 1.92 to 7.54, P = 0.0010); and (6) the mental component of the SF-36, 3.42 (95% CI 0.27 to 6.56, P = 0.03). CONCLUSION:: Exercise intervention is more effective in fatigue, anxiety, depression, physical activity, and QOL. However, large-scale randomized controlled trials are needed to confirm the appropriate types of exercise and optimal time for patients with end-stage renal disease.

Feasibility and effectiveness of pre-emptive rehabilitation in persons approaching dialysis (PREHAB).

INTRODUCTION: End-stage kidney disease (ESKD) is characterised by several complications, leading to reduced functional ability and quality of life during transition to dialysis. This study aimed to establish the feasibility and effectiveness of a patient-centred programme of exercise, nutritional intervention and multidisciplinary education for persons approaching dialysis. METHODS: Patients with eGFR <15 ml/min/1.73 m2 and anticipated to start dialysis within 6-12 months were invited to participate. The 10-week pre-dialysis intervention included a weekly 1-hour gym-based exercise circuit and an education programme. Feasibility and acceptability were assessed through recruitment and retention rates, adherence to the intervention, and from patient feedback following the intervention. Physical function, nutritional status, and anxiety and depression, were assessed at baseline, after intervention, and as dialysis commenced. RESULTS: Thirty patients agreed to participate, with 22 completing the pre-dialysis intervention. Thirteen (59%) participants achieved 100% attendance at the exercise and education sessions, with only two participants attending less than 8/10 sessions. The intervention also led to improved physical function, demonstrated by significant increase in both incremental shuttle walk distance (330 vs. 385 m, p = 0.006) and quadriceps one repetition maximum (p = 0.007), and a trend towards increased sit-to-stand repetitions (20-23, p = 0.11). There was a trend for improved patient perception of activity (Duke Activity Status Index score 31.55 vs. 33.75, p = 0.09). Hand grip strength (29.1 vs. 29.8 kg), body mass index (30.4 vs. 30.5 kg/m2 ) and nutritional status assessed by subjective global assessment (73% well-nourished) were maintained. CONCLUSION: This study demonstrated the feasibility and effectiveness of a patient-centred exercise and education programme in those approaching dialysis. Further research is therefore required to evaluate the impact of this programme on clinical outcomes.

Prehabilitation prior to kidney transplantation: Results from a pilot study.

Prehabilitation is the process of enhancing preoperative functional capacity to improve tolerance for the upcoming stressor; it was associated with improved postoperative outcomes in a handful of studies, but never evaluated in transplantation. Kidney transplant (KT) candidates may be uniquely suited for prehabilitation because they experience a profound loss of functional capacity while waiting years on dialysis. To better understand the feasibility and effectiveness of prehabilitation in KT, we conducted a pilot study of center-based prehabilitation for candidates; this intervention consisted of weekly physical therapy sessions at an outpatient center with at-home exercises. We enrolled 24 participants; 18 participated in prehabilitation (75% of enrolled; 17% of eligible). 61% were male, 72% were African American, and mean age = 52 (SD = 12.9); 71% of participants had lower-extremity impairment, and 31% were frail. By 2 months of prehabilitation, participants improved their physical activity by 64% (P = 0.004) based on accelerometry. Participants reported high satisfaction. Among 5 prehabilitation participants who received KT during the study, length of stay was shorter than for age-, sex-, and race-matched control (5 vs 10 days; RR = 0.69; 95% CI:0.50-0.94; P = 0.02). These pilot study findings suggest that prehabilitation is feasible in pretransplant patients and may potentially be a strategy to improve post-KT outcomes.

Relationships Between Clinical Processes and Arteriovenous Fistula Cannulation and Maturation: A Multicenter Prospective Cohort Study.

BACKGROUND: Half of surgically created arteriovenous fistulas (AVFs) require additional intervention to effectively support hemodialysis. Postoperative care and complications may affect clinical maturation. STUDY DESIGN: Hemodialysis Fistula Maturation (HFM) Study, a 7-center prospective cohort study. SETTING & PARTICIPANTS: 491 patients with single-stage AVFs who had neither thrombosis nor AVF intervention before a 6-week postoperative ultrasonographic examination and who required maintenance hemodialysis. PREDICTORS: Postoperative care processes and complications. OUTCOMES: Attempted cannulation, successful cannulation, and unassisted and overall clinical maturation as defined by the HFM Study criteria. RESULTS: AVF cannulation was attempted in 443 of 491 (90.2%) participants and was eventually successful in 430 of these 443 (97.1%) participants. 263 of these 430 (61.2%) reached unassisted and 118 (27.4%) reached assisted AVF maturation (overall maturation, 381/430 [88.6%]). Attempted cannulation was less likely in patients of surgeons with policies for routine 2-week versus later-than-2-week first postoperative visits (OR, 0.21; 95% CI, 0.06-0.70), routine second postoperative follow-up visits (OR, 0.39; 95% CI, 0.15-0.97), and a routine clinical postoperative ultrasound (OR, 0.28; 95% CI, 0.14-0.55). Attempted cannulation was also less likely among patients undergoing procedures to assist maturation (OR, 0.51; 95% CI, 0.27-0.98). Unassisted maturation was more likely for patients treated in facilities with access coordinators (OR, 1.91; 95% CI, 1.17-3.12), but less likely after precannulation nonstudy ultrasounds (OR per ultrasound, 0.42 [95% CI, 0.26-0.68]) and initial unsuccessful cannulation attempts (OR per each additional attempt, 0.90 [95% CI, 0.83-0.98]). Overall maturation was less likely with infiltration before successful cannulation (OR, 0.44; 95% CI, 0.22-0.89). Among participants receiving maintenance hemodialysis before AVF surgery, unassisted and overall maturation were less likely with longer intervals from surgery to initial cannulation (ORs for each additional month of 0.81 [95% CI, 0.76-0.88] and 0.93 [95% CI, 0.89-0.98], respectively) and from initial to successful cannulation (ORs for each additional week of 0.87 [95% CI, 0.81-0.94] and 0.88 [95% CI, 0.83-0.94], respectively). LIMITATIONS: Surgeons' management policies were assessed only by questionnaire at study onset. Most participants received upper-arm AVFs, planned 2-stage AVFs were excluded, and maturation time windows were imposed. Some care processes may have been missed and the observational design limits causal attribution. CONCLUSIONS: Multiple processes of care and complications are associated with AVF maturation outcomes.

Validity, reliability and minimal detectable change of the balance evaluation systems test (BESTest), mini-BESTest and brief-BESTest in patients with end-stage renal disease.

PURPOSE: This study determined the validity, test-retest reliability and minimal detectable change of the balance evaluation systems test (BESTest), mini-balance evaluation systems test (Mini-BESTest) and brief-balance evaluation systems test (Brief-BESTest) in patients with end-stage renal disease. METHODS: A cross-sectional study with 74 patients with end-stage renal disease (male 66.2%; 63.9 ± 15.1 years old) was conducted. Participants were asked to report the number of falls during the previous 12 months and to complete the activity-specific balance confidence (ABC) scale. The BESTest was administered, and the Mini-BESTest and Brief-BESTest scores were computed based on the BESTest performance. Validity was assessed by correlating balance tests with each other and with the ABC scale. Test-retest relative reliability and agreement were explored with the intraclass correlation coefficient (ICC) equation (2,1) and the Bland and Altman method. Minimal detectable changes at the 95% confidence level were established. RESULTS: Balance test scores were significantly correlated with each other (spearman's correlation = 0.89-0.92) and with the ABC scale (spearman's correlation = 0.49-0.59). Balance tests presented high test-retest reliability (ICC = 0.84-0.94), with no evidence of bias. Minimal detectable change values were 10.8 (expressed as a percentage 13.5%), 5.3 (23.7%) and 5.6 (34%) points for the BESTest, Mini-BESTest and Brief-BESTest, respectively. CONCLUSIONS: All tests are valid and reliable to assess balance in patients with end-stage renal disease. Nevertheless, based on the minimal detectable changes found, BESTest and Mini-BESTest may be the most recommended tests for this specific population. Implications for Rehabilitation Balance evaluation systems test (BESTest), mini-balance evaluation systems test (Mini-BESTest) and brief-balance evaluation systems test (Brief-BESTest) are reliable and valid in patients with end stage renal disease (ESRD). The minimal detectable changes of 10.8 for the BESTest, 5.3 for the Mini-BESTest and 5.6 for the Brief-BESTest can be used by clinicians to identify a true change in balance over time or in response to interventions. Based on the minimal detectable changes found, BESTest and Mini-BESTest may be the most recommended; and the selection of one of them may be based on time and equipment availability.

Prehabilitation for kidney transplant candidates: Is it time?

Many patients become frail with diminished cardiorespiratory fitness while awaiting kidney transplantation. Frailty and poor fitness powerfully predict mortality, transplant graft survival, and healthcare utilization after kidney transplantation. Efforts to intervene with post-transplant physical therapy have been met with limited success, in large part due to high study dropout. We reviewed the literature on chronic kidney disease and exercise to propose a clinical framework for physical therapy interventions to improve fitness, scheduled for before the transplant. This framework may lead to better patient retention and compliance, and thus demonstrate better efficacy in mitigating the effects of frailty and poor fitness after kidney transplantation.

Physical performance and protein-energy wasting in patients treated with nocturnal haemodialysis compared to conventional haemodialysis: protocol of the DiapriFIT study.

BACKGROUND: Poor physical performance and protein-energy wasting (PEW) are health issues of major concern in haemodialysis patients. The conventional haemodialysis (CHD) regime, three times per week 3-5 h, is subject of discussion because of high morbidity and mortality rates. When patients switch from CHD to longer dialysis sessions, i.e. nocturnal haemodialysis (NHD), improvement in protein intake and increase in body weight is seen. However, it is unclear whether physical performance and more important aspects of PEW, such as body composition, improve as well. Therefore, the aim of this study is to investigate whether physical performance improves and PEW decreases, when patients switch from CHD to NHD. A second aim is to assess the influence of NHD on the biomarkers fibroblast growth factor-23 and sclerostin which are thought to be associated with malnutrition and mortality in patients on haemodialysis. METHODS: This study is a prospective multicentre cohort study with an inclusion aim of 50 patients: 25 patients in a control group (three times per week, 3-5 h CHD) and 25 patients in a nocturnal group (three times per week, 7-9 h NHD). Primary outcome is change in physical performance, measured by the Short Physical Performance Battery. Additional measurements are a 6-min walk test, handgrip strength, a physical activity questionnaire and physical activity monitoring. The secondary outcome of the study is PEW, which will be evaluated by body weight, dual-energy X-ray absorptiometry, bio-electrical impedance spectroscopy, mid-upper arm muscle circumference, subjective global assessment, visual analogue scale for appetite and dietary records. Laboratory measurements including fibroblast growth factor-23 and sclerostin, and quality of life assessed with the Kidney Disease Quality of Life-Short Form are also studied. In every patient, four repeated measurements will be performed during one year of follow-up. DISCUSSION: This study will investigate whether physical performance improves and PEW decreases when patients switch from CHD to NHD, compared to a control group who continue treatment with CHD. Strengths of this study are the comparison with a conventional haemodialysis cohort, and the broad variety of objective measurements combined with patient-reported outcomes of physical performance and PEW. TRIAL REGISTRATION: NTR4715 , Netherlands Trial Register. Registered 30 July 2014.

Statin use and hip fractures in U.S. kidney transplant recipients.

BACKGROUND: Basic and translational research supports beneficial effects of statins on bone metabolism. Clinical studies suggest that statin use may reduce the risk of hip fractures in the general population. Whether statin use is associated with hip fracture risk in kidney transplant recipients, a particularly high-risk group for this outcome, is unknown. METHODS: From the U.S. Renal Data System (2007-2011), we identified all hip fracture events recorded in Medicare billing claims of first-time kidney transplant recipients. We then matched all cases to an unlimited number of controls on age (±3 years), sex, race (black vs. non-black), and time since transplant. Cases and controls were required to have >1 year of Medicare Parts A + B + D coverage and be without a recorded history of hip fracture. We ascertained any statin use in the previous year and defined adherent statin use as those who had filled prescriptions for statins to cover >80% of days in that year (proportion of days covered, PDC). We ascertained several potential confounders (demographics, comorbidities, BMI, transplant-related factors) and applied conditional logistic regression with multiple imputation for missing data to estimate odds ratios (OR) and 95% confidence intervals (CI). RESULTS: We identified 231 hip fracture cases (mean age 51.8 years; 53% female; 11.3% black; 6.9 years from transplant, and 9.9 years from ESRD) and 15,575 matched controls. Any prior statin use was present in 64.1% of cases and 60.3% of controls with 37.2% of cases and 33.9% of controls being found adherent. Unadjusted conditional logistic regression showed an OR of 1.17 (0.89-1.54) for any statin use, and a fully-adjusted OR of 0.89 (0.67-1.19). Compared with statin non-users, the adjusted OR for patients with lesser adherence (PDC ≤80%) and those with greater adherence (PDC >80%) were 0.93 (0.66-1.31) and 0.87 (0.63-1.20), respectively. CONCLUSION: Statin use was not associated with hip fracture risk in first-time kidney transplant recipients.

Quality of life in patients on chronic dialysis in South Africa: a comparative mixed methods study.

BACKGROUND: The increasing prevalence of treated end-stage renal disease and low transplant rates in Africa leads to longer durations on dialysis. Dialysis should not only be aimed at prolonging lives but also improve quality of life (QOL). Using mixed methods, we investigated the QOL of patients on chronic haemodialysis (HD) and peritoneal dialysis (PD). METHODS: We conducted a cross-sectional study at Tygerberg Hospital in Cape Town, South Africa. All the PD patients were being treated with continuous ambulatory peritoneal dialysis. The KDQOL-SF 1.3 questionnaire was used for the quantitative phase of the study. Thereafter, focus-group interviews were conducted by an experienced facilitator in groups of HD and PD patients. Electronic recordings were transcribed verbatim and analysed manually to identify emerging themes. RESULTS: A total of 106 patients completed questionnaires and 36 of them participated in the focus group interviews. There was no difference between PD and HD patients in the overall KDQOL-SF scores. PD patients scored lower with regard to symptoms (P = 0.005), energy/fatigue (P = 0.025) and sleep (P = 0.023) but scored higher for work status (P = 0.005) and dialysis staff encouragement (P = 0.019) than those on HD. Symptoms and complications were verbalised more in the PD patients, with fear of peritonitis keeping some housebound. PD patients were more limited by their treatment modality which impacted on body image, sexual function and social interaction but there were less dietary and occupational limitations. Patients on each modality acknowledged the support received from family and dialysis staff but highlighted the lack of support from government. PD patients had little opportunity for interaction with one another and therefore enjoyed less support from fellow patients. CONCLUSIONS: PD patients experienced a heavier symptom burden and greater limitations related to their dialysis modality, especially with regards to social functioning. The mixed-methods approach helped to identify several issues affecting quality of life which are amenable to intervention.

A prospective 2-site parallel intervention trial of a research-based film to increase exercise amongst older hemodialysis patients.

BACKGROUND: Evidence suggests that exercise training for hemodialysis patients positively improves morbidity and mortality outcomes, yet exercise programs remain rare and are not systematically incorporated into care. We developed a research-based film, Fit for Dialysis, designed to introduce, motivate, and sustain exercise for wellness amongst older hemodialysis patients, and exercise counseling and support by nephrologists, nurses, and family caregivers. The objective of this clinical trial is to determine whether and in what ways Fit for Dialysis improves outcomes and influences knowledge/attitudes regarding the importance of exercise for wellness in the context of end-stage renal disease. METHODS/DESIGN: This 2-site parallel intervention trial will recruit 60 older hemodialysis patients from two urban hospitals. The trial will compare the film + a 16-week exercise program in one hospital, with a 16-week exercise-only program in another hospital. Physical fitness and activity measures will be performed at baseline, 8 and 16 weeks, and 12 weeks after the end of the program. These include the 2-min Walk Test, Grip Strength, Duke Activity Status Index, and the Timed Up-and-Go Test, as well as wearing a pedometer for one week. Throughout the 16-week exercise program, and at 12 weeks after, we will record patients' exercise using the Godin Leisure-time Exercise Questionnaire. Patients will also keep a diary of the exercise that they do at home on non-dialysis days. Qualitative interviews, conducted at baseline, 8, and 16 weeks, will explore the impact of Fit for Dialysis on the knowledge/attitudes of patients, family caregivers, and nephrology staff regarding exercise for wellness, and in what ways the film is effective in educating, motivating, or sustaining patient exercise during dialysis, at home, and in the community. DISCUSSION: This research will determine for whom Fit for Dialysis is effective, why, and under what conditions. If Fit for Dialysis is proven beneficial to patients, nephrology staff and family caregivers, research-based film as a model to support exercise promotion and adherence could be used to support the National Kidney Foundation's guideline recommendation (NKF-KDOQI) that exercise be incorporated into the care and treatment of dialysis patients. TRIAL REGISTRATION: NCT02754271 (ClinicalTrials.gov), retroactively registered on April 21, 2016.