Influence of intradialytic systolic blood pressure changes on arteriovenous access thrombosis in maintenance hemodialysis patients.

BACKGROUND: Arteriovenous access (AV) thrombosis is an important and preventable problem amongst chronic hemodialysis (HD) patients. Systolic blood pressure (SBP) fluctuation relates to higher cardiovascular mortality amongst these patients. We proposed there is a close relation between SBP changes and arteriovenous (AV) access thrombosis. We also determined other risk factors and biochemical parameters related to AV access failure. METHODS: 50 HD patients with thrombosis and 50 HD patients without thrombosis were included in the study. Odds ratios and 95% confidence intervals were estimated with multivariate-adjusted logistic regression models to determine the association between potential thrombosis-related risk factors and thrombosis risk. RESULTS: Elder adults, women, and patients with AV grafts, lower intradialytic SBP and higher SBP variations during HD sessions had higher incidence of AV access thrombosis. AV access infection and decreased blood flow (BF) velocity were associated with an increased incidence of thrombotic events, whereas the use of anti-thrombotic agents was associated with a decreased incidence of thrombotic events. Further, anaemia, hypoalbuminemia, hyperlipidemia, and impaired mineral metabolism parameters were also found to be associated with AV access thrombosis. CONCLUSIONS: Close monitoring and management of intradialytic hypotension and SBP fluctuation in every HD session are important. Some important and novel modifiable risk factors related to AV access thrombosis were identified in this study (eg, AV access infection, decreased BF and abnormal biochemical parameters, etc). Earlier surveillance and modification of these risk factors is crucial to prevent AV access failure in HD patients.

Twelve-week intradialytic cycling exercise improves physical functional performance with gain in muscle strength and endurance: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of intradialytic cycling exercise on physical functional performance with gain in muscle strength and endurance in end-stage renal disease patients with haemodialysis. DESIGN: Randomized controlled trial, with repeated measurements at baseline and after 4, 8, and 12 weeks of intradialytic cycling exercise. SETTING: A 50-bed haemodialysis centre in a regional hospital in Taiwan. SUBJECTS: Seventy-six regular haemodialysis patients, recruited and equally and randomly assigned to exercise and control groups. INTERVENTION: The intradialytic cycling exercise was performed for 12 weeks and comprised warm-up, main, and cool-down exercise phases. A stationary cycling equipment was used, which involved aerobic and resistance modalities. The intensity was maintained at somewhat hard exertion. Each intradialytic cycling exercise was implemented for 30 minutes, starting at the second hour of treatment. MAIN MEASURE: Measured outcomes were 6-minute walk distance, time taken to complete 10 sit-to-stand-to-sit cycles and number of sit-to-stand-to-sit cycles in 60 seconds. RESULTS: Average (standard deviation) participant age was 55.47 (13.00) years. Therefore, the 6-minute walk distance was significantly different at weeks 8 (P = 0.01) and 12 (P < 0.001) in the exercise group compared with that in the control group at baseline. Notably, sit-to-stand-to-sit outcomes (P = 0.01) significantly influenced the 6-minute walk distance. Sit-to-stand-to-sit outcomes significantly improved in the exercise group (P < 0.05). CONCLUSION: Twelve-week intradialytic exercise for patients on haemodialysis can improve physical functional performance with gain muscle strength and endurance. This is a safe and effective method for improving health.

Effects of intradialytic exercise on the physical function, depression and quality of life for haemodialysis patients: a systematic review and meta-analysis of randomised controlled trials.

AIMS AND OBJECTIVES: To determine the efficacy and safety of intradialytic exercises for haemodialysis patients, this study conducted a systematic review and meta-analysis of randomised controlled trials. BACKGROUND: Patients receiving haemodialysis have poor physical function, psychological status and quality of life than the general population. Exercise training may improve these parameters for haemodialysis patients. DESIGN: Systemic review was performed, and a meta-analysis was conducted. METHODS: Medline, PubMed, Cochrane Central Register of Controlled Trials, SPORTDiscus, Cumulative Index to Nursing and Allied Health Literature and Airiti Library were systematically searched for studies up to January 2015. In addition, the reference lists of eligible studies and relevant reviews were assessed. RESULTS: Seventeen studies with a total of 651 participants were included. Compared with no resistance exercise, nonexercise and walks at home, intradialytic exercises significantly improved the peak oxygen consumption (SMD = 0·50, 95% CI: 0·26-0·74), haemoglobin (SMD = 0·34, 95% CI: 0·13-0·55), depression (SMD = -0·80, 95% CI: -1·10 to -0·50) and physical component of the quality of life (SMD = 0·46, 95% CI: 0·20-0·73). Intradialytic exercises are safe with no adverse events. However, significant improvements were not observed in the albumin level and mental component of the quality of life. CONCLUSIONS: The study results facilitate selecting intradialytic exercise that improves and provides safety with respect to the peak oxygen consumption, haemoglobin, depression and physical component of the quality of life. Furthermore, regular exercise should be considered a crucial therapeutic modality for patients undergoing haemodialysis. RELEVANCE TO CLINICAL PRACTICE: This study suggests that performing intradialytic exercises for 30 minutes per session three times a week for at least ≥8 weeks is beneficial. Regular exercise should be considered as a crucial therapeutic modality of managing patients undergoing haemodialysis, thus guiding in clinical practice.

Glycated Albumin Predicts Long-term Survival in Patients Undergoing Hemodialysis.

BACKGROUND: In patients with advanced renal dysfunction undergoing maintenance hemodialysis, glycated albumin (GA) levels may be more representative of blood glucose levels than hemoglobin A1C levels. The aim of this study was to determine the predictive power of GA levels on long-term survival in hemodialysis patients. METHODS: A total of 176 patients with a mean age of 68.2 years were enrolled. The median duration of follow-up was 51.0 months. Receiver-operating characteristic curve analysis was utilized to determine the optimal cutoff value. We examined the cumulative survival rate by Kaplan-Meier estimates and the influence of known survival factors with the multivariate Cox proportional-hazard regression model. RESULTS: In the whole patient group, cumulative survival in the low GA group was better than in the high GA group (p=0.030), with more prominence in those aged <70 years (p=0.029). In subgroup analysis, both diabetic (DM) and non-DM patients with low GA had a better cumulative survival compared with those with high GA. The risk of mortality increased by 3.0% for each 1% increase in serum GA level in all patients undergoing hemodialysis. CONCLUSIONS: In addition to serving as a glycemic control marker, GA levels may be useful for evaluating the risk of death in both DM and non-DM patients on hemodialysis.

The relationship between health-promoting behaviors and resilience in patients with chronic kidney disease.

This cross-sectional research study explored differences in health-promoting behavior and resilience among three groups of chronic kidney disease patients (high-risk, early chronic kidney disease; early CKD and pre-end stage renal disease; pre-ESRD) treated at the Nephrology outpatient clinic in northern Taiwan. A total of 150 CKD outpatients were interviewed using structured questionnaires including a CKD Health to Promote Lifestyle Scale, and resilience scale. We found that the pre-ESRD group had lower resilience than either high-risk or early CKD groups. Factors affecting pre-ESRD resilience were gender, occupational status, diabetes and health-promoting behaviors. Factors affecting resilience of the high-risk group included level of education and health-promoting behaviors while factors affecting resilience in the early CKD group involved whether they are employed and health promoting behaviors. A significant positive correlation was found between health promoting behavior and resilience in all study subjects. Multiple regression analysis found that factors which could effectively predict resilience in patients at high-risk for CKD were gender, whether the patient had a job, nutrition, self-actualization, and stress level, accounting for 69.7% of the variance. Therefore, nursing education should focus on health promotion advocacy throughout the life of not only patients but also their families.

[Improving physiological and psychological status in a hemodialysis patient: a nursing experience using an exercise training program].

Exercise training during hemodialysis has been found to improve functional capacity, nutritional status, cardiovascular risk factors, depression, and well being in hemodialysis patients. This report describes a nursing experience that applied exercise training to improve activity intolerance, powerlessness, and ineffective health maintenance in a hemodialysis patient. The care period was from May 11 to July 27, 2012. The author collected information using observation, interview, physical examination, and medical record review and identified patient care problems including activity intolerance, powerlessness, and ineffective health maintenance. In addition to providing individual nursing interventions, the author designed a stationary bicycle installed at the end of the bed. The patient was asked use the bicycle to exercise 30 mins per time, three times per week for a period of 12 weeks during the patient's hemodialysis period. Before and after a 12-week of exercise training, collected the 6-minute walk test (6MWT), self-perceived improvement, and self-reported depression scales were performed prior to and after completion of the intervention. Hematological triglyceride, albumin, and hemoglobin data were collected each week. Heart rate, blood pressure, and oxygen saturation were examined prior to and after the intervention to ensure patient safety. After the 12-week intervention, the average heart rate achieved 40-60% of the maximum heart rate and the heart rate peaked between 85 and 121 bpm. Moreover, the 6MWT distance increased from 210 m to 255 m, triglyceride decreased from 622 mg/dL to 173 mg/dL, and self-perceived fatigue and depression markedly improved. This nursing experience is shared with nurses caring for patients with similar conditions.

Indoxyl sulfate mediates low handgrip strength and is predictive of high hospitalization rates in patients with end-stage renal disease.

Background and aims: Sarcopenia has a higher occurrence rate in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) than in the general population. Low handgrip strength-and not sarcopenia per se-is associated with clinical outcomes in patients with CKD, including cardiovascular mortality and hospitalization. The factors contributing to low handgrip strength are still unknown. Accordingly, this study aimed to determine whether uremic toxins influence low handgrip strength in patients with CKD. Materials and methods: This cohort study lasted from August 2018 to January 2020. The participants were divided into three groups: the control group [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min], an advanced CKD group (eGFR = 15-60 ml/min), and an ESRD group (under maintenance renal replacement therapy). All participants underwent handgrip strength measurement, dual-energy X-ray absorptiometry, and blood sampling for myokines (irisin, myostatin, and interleukin 6) and indoxyl sulfate. Sarcopenia was defined according to the Asian Working Group for Sarcopenia consensus as low appendicular skeletal muscle index (appendicular skeletal muscle/height2 of < 7.0 kg/m2 in men and < 5.4 kg/m2 in women) and low handgrip strength (< 28 kg in men and < 18 kg in women). Results: Among the study participants (control: n = 16; CKD: n = 17; and ESRD: n = 42), the ESRD group had the highest prevalence of low handgrip strength (41.6 vs. 25% and 5.85% in the control and CKD groups, respectively; p < 0.05). The sarcopenia rate was similar among the groups (12.5, 17.6, and 19.5% for the control, CKD, and ESRD groups, respectively; p = 0.864). Low handgrip strength was associated with high hospitalization rates within the total study population during the 600-day follow-up period (p = 0.02). The predictions for cardiovascular mortality and hospitalization were similar among patients with and without sarcopenia (p = 0.190 and p = 0.094). The serum concentrations of indoxyl sulfate were higher in the ESRD group (227.29 ± 92.65 µM vs. 41.97 ± 43.96 µM and 6.54 ± 3.45 µM for the CKD and control groups, respectively; p < 0.05). Myokine concentrations were similar among groups. Indoxyl sulfate was associated with low handgrip strength in univariate and multivariate logistic regression models [univariate odds ratio (OR): 3.485, 95% confidence interval (CI): 1.372-8.852, p = 0.001; multivariate OR: 8.525, 95% CI: 1.807-40.207, p = 0.007]. Conclusion: Handgrip strength was lower in the patients with ESRD, and low handgrip strength was predictive of hospitalization in the total study population. Indoxyl sulfate contributed to low handgrip strength and counteracted the benefits of myokines in patients with CKD.

Disease Knowledge, Self-Efficacy, and Quality of Life in Patient With Hypertensive Nephropathy.

The purpose of this study is to investigate the relationships among disease knowledge, self-efficacy, and quality of life in patients with hypertensive nephropathy. A cross-sectional and correlational design is employed in this study, and a total of 213 participants are collected by convenience sampling from the outpatient Department of Nephrology of a regional teaching hospital in Taiwan. The research instruments include the Hypertensive Nephropathy Knowledge Instrument, the Chronic Kidney Disease Self-Efficacy Instrument, and the Medical Outcome Study Short Form-12, and stepwise multiple regression analysis is used to test the explanatory power of each significantly-correlated independent variable regarding the quality of life. The results show that the higher the disease knowledge, the better the self-efficacy, and the better the quality of life, and self-efficacy is the most important predictor of the quality of life.

Factors Influencing Self-Management Behaviors among Hemodialysis Patients.

AIM: To investigate the factors affecting hemodialysis patients' self-management ability at a dialysis center in Taiwan. BACKGROUND: Taiwan has the highest incidence and prevalence of end-stage kidney disease (ESKD) in the world. Over 90% of patients with ESKD receiving hemodialysis (HD) and self-management behaviors are critical among these patients. Failure to adhere to self-managed care increases the cost of medical care and the risk of morbidity and mortality. METHODS: In this cross-sectional study, a total of 150 HD patients were observed for their self-management behaviors and the factors influencing these behaviors including education level, comorbid conditions, biochemical analysis, depression, and social support, etc., were analyzed. RESULTS: Self-management behaviors in HD patients were significantly impaired in the presence of diabetes mellitus, hypertension, anemia, hypoalbuminemia, and depression. The major predictor of patients' self-management was depression, explaining 14.8% of the total variance. Further addition of social support, hypertension, and diabetes mellitus into the regression model increased the total explained variance to 28.6%. Of the various domains of self-management, the partnership domain received the highest score, whereas emotional processing received the lowest score. CONCLUSIONS: This study found the important factors influencing self-management behaviors; through this acknowledgement and early correction of these factors, we hope to improve HD patients' individual life quality and further decrease their morbidity and mortality.

Effect of multi-disciplinary teaching on learning satisfaction, self-confidence level and learning performance in the nursing students.

AIM: The aim of this study was to design a multidisciplinary teaching method that combines game-based learning with a clinical situation-based teaching program and to test learning motivation, learning satisfaction and self-confidence. BACKGROUND: Research has suggested that game-based learning and clinical situation-based teaching can effectively capture student attention and stimulate student learning motivation as well as increase learning satisfaction and self-confidence. DESIGN: The randomized and experimental design used in this study was a pretest-posttest control group design. METHODS: This study recruited participants from a technical college in the north of Taiwan. The experimental group (receiving multidisciplinary teaching) comprised 48 participants and the control group (receiving traditional teaching) comprised 50 participants. Participants took a pretest before the multidisciplinary teaching intervention, received a total of 12 weeks of intervention and then took a posttest within 1 week of the end of the course. These participants completed a questionnaire regarding learning satisfaction, confidence and learning performance. RESULTS: The multidisciplinary teaching intervention improved learning satisfaction (t = 7.36, p < 0.001), self-confidence (t = 7.34, p < 0.001) and learning performance (t = 6.66, p < 0.001). Multidisciplinary teaching interventions can improve learning satisfaction, self-confidence and learning performance among nursing students. CONCLUSIONS: Multidisciplinary teaching should be promoted in the context of nursing teaching and students have the multidisciplinary learning.

Role of resilience and social support in alleviating depression in patients receiving maintenance hemodialysis.

BACKGROUND: Patients who undergo hemodialysis encounter challenges including role changes, physical degeneration, and difficulty in performing activities of daily living (ADLs) and self-care. These challenges deteriorate their physiological and psychosocial conditions, resulting in depression. High resilience (RES) and social support can alleviate stress and depression. This study evaluated the importance of RES and social support in managing depression in elderly patients undergoing maintenance hemodialysis (HD). PATIENTS AND METHODS: In this descriptive, correlational study, 194 older patients undergoing HD were enrolled from the HD centers of three hospitals in northern Taiwan. The Barthel ADL Index, RES scale, Inventory of Socially Supportive Behavior, and Beck Depression Inventory-II were used. Hierarchical regression analysis was applied to evaluate the interaction of RES and social support with illness severity, demographics, and ADLs. RESULTS: Of the total participants, 45.9% experienced depressive symptoms. Demographic analysis showed that men and those with high educational level and income and financial independence had less depression (p<0.01). Patients with a higher Barthel Index (n=103), RES scale (n=33), and social support (n=113) showed less depressive symptoms (p<0.01). We found a significant negative correlation between depressive symptoms and social support (r=-0.506, p<0.01) and RES (r=-0.743, p<0.01). Hierarchical regression analysis showed that RES could buffer the effects of symptom severity on depression (b=-0.436, p<0.01), but social support did not exert a buffering effect. CONCLUSION: The severity of illness symptoms and ADLs were the major determinants of depressive symptoms. High RES could alleviate depressive symptoms in the older patients undergoing HD.

Effects of aerobic exercise during hemodialysis on physical functional performance and depression.

Previous studies have concluded that exercise training is beneficial to patients on hemodialysis (HD). Results, however, have shown that differences in the type, intensity, and frequency of physical exercise lead to variability in its effects on physical functional performance and depression. Further research is thus warranted. Our aim was to evaluate the effects of aerobic exercise on physical functional performance and depression during HD. Using a pretest-posttest control group design, we recruited HD patients and nonrandomly assigned them to an exercise group (n = 13) that completed a 12-week aerobic exercise program during HD or a control group (n = 11) that did no exercise during HD. The primary outcome measures were physical functional performance, as evaluated by the 6-min walk test and the sit-to-stand test, and depression, as evaluated by the Beck Depression Inventory II. The secondary outcome measures were albumin and triglyceride levels and hematocrit. Results revealed significant between-group differences in physical functional performance and depression but not in albumin level, hematocrit, or triglyceride level. Findings suggest that exercise may play a critical role in physical functional performance and may decrease depression. Exercise should be encouraged and performed during HD in HD centers.