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Objectives: To examine the association of several psychosocial disorders with quality of life (QoL) among chronic hemodialysis patients., Methods: A cross-sectional observational study was conducted in 2018 and recruited chronic hemodialysis patients from 3 major hemodialysis centers in Riyadh, Kingdom of Saudi Arabia (KSA). Quality of life was assessed using a previously validated Arabic version of the dialysis version-III of the QoL index., Results: A total of 101 patients (56 males and 45 females) were included. The mean age was 54.0±12.3 years. The overall mean of QoL was 88.8/100 points (out of 100). The family (95.0%) and psychological/spiritual (94.7%) domains had the highest scores. The prevalence of psychosocial disorders was 24.8% for depressive symptoms, 15.8% for anxiety symptoms, 88.1% for cognitive impairment, 76.8% for insecure attachment style, and 38.6% for medium/high severity of somatic symptoms. All psychosocial disorders and higher cognition level were negatively correlated with QoL (Spearman correlation r ranged between -0.228- -0.468). After adjusting for sociodemographic and clinical characteristics, anxiety symptoms and higher cognition level were independent predictors of poor QoL, while marital status (married) was an independent predictor of good QoL., Conclusion: We report higher QoL and relatively better psychosocial profiles among current chronic hemodialysis patients than reported before. Psychosocial disorders specially anxiety can negatively impact QoL. Patients who were not cognitively impaired were more negatively affected in QOL. The findings re-emphasize the importance of the early detection and management of psychosocial disorders to improve QoL in chronic hemodialysis patients.

Patient experience is an integral aspect of the care we deliver to our dialysis patients. Standardized evaluation of patient experience with in-center hemodialysis started in the United States in 2012 with the In-Center Hemodialysis Consumer Assessment of Healthcare Providers and Systems (ICH CAHPS) survey. Over time there have been a few changes to this survey, how it is administered, and how it fits within the Centers for Medicare & Medicaid Services End-Stage Renal Disease Quality Incentive Program. Although the importance of this survey has been growing, knowledge of this survey among nephrologists has lagged. We provide a review of the survey development and how its use has evolved since 2012. We discuss in detail research done on this survey to date, including survey psychometric evaluation. We highlight gaps in our knowledge that need further research and end with general recommendations to improve patient experience within hemodialysis facilities, which we believe is a worthy goal for all members of the dialysis team., (Copyright © 2020 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: Evaluate the effect of watching comedy movies as a complementary practice during dialysis on levels of anxiety, depression, quality of life, stress, laboratory findings and intra-dialysis complications., Methods: A randomized clinical trial was conducted involving the practice of presenting comedy movies during dialysis. The primary outcome was depression. The secondary outcomes were anxiety, quality of life, stress, laboratory findings and intra-dialysis complications.ResultsTwenty-six patients were in the control group and 35 were in the experimental group. Significant intra-group differences [6.0 to 3.0 (p <0.001) and 8.0 to 4.0 (p <0.001), respectively] and inter-group differences [5.0 vs. 3.0 (p = 0.016) and 7.0 vs. 4.0 (p = 0.017), respectively] were found regarding anxiety and depression scores, with improvements in the experimental group. The experimental group was also less likely to have intra-dialysis complications, such as hypertension (p = 0.003) and headache (p = 0.020), and reported significant improvements in different domains of quality of life [symptoms/problems (p = 0.003); effects of the disease (p = 0.008); pain (p = 0.027); general health state (p = 0.004); and social function (p = 0.036)]. No significant differences were found in salivary cortisol or the results of the biochemical exams, with the exception of a reduction in hematocrit in the control group.ConclusionsThe proposed complementary practice was associated with reductions in anxiety and depression scores and intra-dialysis complications (hypertension and headache) as well as improvements in quality of life in patients with chronic kidney disease., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

This study examined differences in caregiving appraisal between primary family caregivers of disabled older adults receiving hemodialysis (PFCGs-wHD) and disabled older adults not receiving dialysis (PFCGs-woD). A total of 242 PFCGs-wHD and 335 PFCGs-woD were included in the analyses. We used adjustment by propensity score to control for bias by confounding factors. Caregiving appraisal was measured in terms of role strain, emotional exhaustion, and caregiving satisfaction. On the first task, PFCGs-wHD demonstrated significantly worse levels on all three appraisal indicators than did PFCGs-woD. On the second task, only higher emotional exhaustion was significantly mediated by higher role strain in PFCGs-wHD. Further, PFCGs-wHD status directly influenced lower caregiving satisfaction without mediation by higher role strain. Caregiving for disabled older adults receiving HD may be associated with significant challenges for caregivers., (© 2019 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Cardiovascular disease-associated morbidity and mortality are reportedly higher in hemodialysis (HD) patients compared with peritoneal dialysis (PD) patients. However, few studies have estimated changes in state of depression and cognitive impairment in patients undergoing HD and PD. The present study evaluated the impact of HD or PD on patients' quality of life (QoL), cognitive impairment, and depression status over 2 years. This 24-month observational, prospective study included 45 HD and 30 PD patients. Patients were assessed before and every 12 months after starting dialysis for 24 months. Measurements included QoL (36-Item Short-Form Health Survey [SF-36]), cognitive impairment (Mini-Mental State Examination [MMSE]), depressive state (Center for Epidemiologic Studies Depression Scale [CES-D]), grip strength, and 24-h urine volume (UV). Physical and social component scores of the SF-36 significantly improved in PD patients at 24 months compared with those observed at baseline (42.8 vs. 39.4; P < 0.05 and 46.4 vs. 37.3; P < 0.05, respectively); however, scores remained unchanged in HD patients. MMSE scores were significantly decreased at 12 and 24 months in HD patients (29.0 vs. 26.0, 25.0; P < 0.05), but remained unchanged in PD patients. Moreover, CES-D scores significantly worsened at 24 months in HD patients (12.8 vs. 16.5), but remained unchanged in PD. Preservation of UV and grip strength was associated with SF-36, CES-D, and MMSE scores. Our findings indicate that PD is associated with higher QoL and recovery from cognitive failure compared with HD., (© 2019 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Objectives: A well-functioning vascular access is crucial for hemodialysis treatment, and arteriovenous fistula is the recommended vascular access type. Arteriovenous fistula is superior to other vascular access types in many aspects, but the effect of arteriovenous fistula on patients' psychiatric state is not well described yet. The aim of this study is to determine whether there is an association between vascular access type and depression scores., Methods: This cross-sectional study was conducted at two hemodialysis centers. Geriatric Depression Scale-15 was administered to geriatric hemodialysis patients, using ≥5 score as the cut-off value for the presence of depressive symptoms. Descriptive tests, Kolmogorov-Smirnov test, Pearson's Chi-square test, Mann-Whitney test, Kruskal-Wallis test, Spearman's rank correlation calculation, and multiple logistic regression analysis were performed accordingly to analyze the data., Results: Of 75 participants, 34 (45.3%) were female and the mean age was 73.4 ± 5.9 years (range: 65-92). The prevalence of depressive symptoms in the geriatric hemodialysis population was 53.3%. Central venous catheter, hypertension, and increased time on hemodialysis have been found to be risk factors for higher depression scores (aOR 10.505 (95% CI 1.435-76.900), p  = 0.021; aOR 9.783 (95% CI 2.508-38.169), p  = 0.001; aOR 1.019 (95% CI 1.003-1.035), p  = 0.017, respectively). Among patients with arteriovenous fistula, those with hypertension had higher depression scores ( p  = 0.008)., Conclusions: Geriatric hemodialysis patients were found to have depressive symptoms commonly, and central venous catheter, hypertension, and increased time on hemodialysis have been found to be risk factors for presence of depressive symptoms. To the best of our knowledge, this is the first study highlighting that arteriovenous fistula is associated with lower depression scores and lower prevalence of depressive symptoms.

Aims and Objectives: To examine the influence of psycho-social and educational interventions on improving adherence to dialysis for patients with end-stage renal disease., Background: Adherence to the complex regimen is poor, contributing to avoidable hospitalisation and morbidity. Psycho-social and educational interventions may be beneficial coping strategies., Design: Systematic literature review and meta-analysis were conducted., Methods: We conducted a systematic search of 8 databases from their inceptions to 16 January 2019 to identify relevant articles. Only randomised controlled trials (RCTs) were included in the analysis. The PRISMA checklist was used., Results: A total of forty RCTs were included to evaluate the effect. The aggregated results of the studies showed that psycho-social and educational interventions elevated adherence rate in both peritoneal dialysis (PD) and haemodialysis (HD) patients. For physiological and biochemical indicators, meta-analysis revealed that significant post-treatment effects were evident for interdialytic weight gain (IDWG), IDWG/dry weight, serum potassium, phosphate, creatinine and blood urea nitrogen (BUN), except for albumin. In particular, subgroup analysis indicated that only the interventions carried out individually exerted significant combined effect for lowering IDWG. As for subjective measures, meta-analysis also revealed small but significant combined effects., Conclusions: The results of this meta-analysis suggest that psycho-social and educational interventions were associated with significant effects on adherence in patients receiving dialysis regimen., Relevance to Clinical Practice: The analysis suggests that psycho-social and educational interventions should be considered as effective strategies for enhancing adherence to dialysis in adults with end-stage renal disease. The potential utility of these interventions should focus on how best to promote individually implementation in clinical practice., (© 2020 John Wiley & Sons Ltd.)

Background: Functional dependence is highly prevalent in maintenance hemodialysis (MHD) settings. Also, poor health-related quality of life (HRQoL) and high levels of depressive symptoms have been reported by MHD patients. We investigated associations between functional status and mental aspects of quality of life in Brazilian MHD patients., Methods: Cross sectional study of 235 patients enrolled in two of the four participating MHD clinics of the Prospective Study of the Prognosis of Chronic Hemodialysis Patients (PROHEMO) in Salvador, BA, Brazil. Data were collected from September 2016 to August 2017. The Katz's questionnaire was used for basic activities of daily living (ADL) and the Lawton-Brody's questionnaire for instrumental activities of daily living (IADL). ADL and IADL scores were combined to create 3 functional status groups: highly dependent (n = 47), moderately dependent (n = 109) and independent (n = 82). The validated Brazilian version of the Kidney Disease Quality of Life Short Form (KDQOL-SF) was used for scores of two distinct HRQoL measures, i.e., the mental component summary (MCS) and the 5-item mental health inventory (MHI-5). We used linear regression to estimate differences in scores with adjustment for possible confounders: months of dialysis, age, gender, other sociodemographic variables, body mass index, type of vascular access, dialysis dose by Kt/V, laboratory variables (albumin, blood hemoglobin, calcium, phosphorus, urea, creatinine and parathyroid hormone) and nine comorbid conditions., Results: Mean age was 51.2 ± 12.4 yr (median age = 51.0 yr), 59.1% were male, 93.2% were non-White. The prevalence of self-reported functional status differed by age: 54.4% for age < 45 yr, 67.8% for age 45-60 yr and 73.9% for age ≥ 60 yr. Using functionally independent as reference, lower scores were observed for highly dependent patients in MCS (difference: -4.69, 95% CI: -8.09, -0.29) and MHI-5 (difference: -5.97, 95% CI: -8.09, -1.29) patients. These differences changed slightly with extensive adjustments for covariates., Conclusions: Our results call attention to a high prevalence of functional dependence in younger and older MHD patients. The results suggest that the lower self-reported mental quality of life in functionally dependent MHD patients cannot be explained by differences in age and comorbidities.

Background: End-stage kidney disease is highly prevalent worldwide. Currently, one of the most effective treatment modalities is dialysis therapy, which leads to serious side effects. Furthermore, psychiatric illnesses are prevalent among dialysis patients. Recently, researchers asserted that psychological resilience and family support could be helpful to maintain or improve patients' mental well-being. Therefore, the purpose of this study was to examine the mediating effects of resilience on the relationship between family functioning and mental well-being in these patients., Methods: To investigate the aim of this study, a cross-sectional design was employed. A total of 110 hemodialysis patients, who were receiving outpatient treatment from dialysis units at the University of Fukuoka and St. Maria Health Care Center in Japan, participated. Only the patients who met the criteria and who were willing to participate in this 30-min study were given The General Health Questionnaire-12, Conner-Davidson Resilience Scale, and Family Assessment Device. Structural Equation Modeling (SEM) was performed to test the hypothesis that resilience would mediate the relationship between each subscale of family functioning, namely, cohesion, adaptability, communication, and mental well-being. Then Sobel's test was employed to examine the indirect effect., Results: The results of the SEM showed that the model had an acceptable fit (RMSEA = .077; CFI = .93; and IFI = .94). According to the results, resilience fully mediated the relationship between family functioning, specifically family adaptability and communication, and mental health well-being of the dialysis patients. However, family cohesion was not associated with resilience., Conclusions: The present study revealed that higher family adaptability and communication resulted in greater resilience, thus associated with better mental health. Given that poor mental health among dialysis patients is significantly associated with a decreased likelihood to adhere to treatment plans, it may lead to a significant risk to therapeutic compliance. As such, patients may experience detrimental consequences, such as death. This study showed that in order to maintain healthy mental well-being, developing resilience is a vital factor for hemodialysis patients.

Aim and Objective: To explore how working-age adults experience patient participation in hospital haemodialysis., Background: End-stage kidney disease is a progressive, chronic condition imposing patients with high treatment burdens and low health-related quality of life. Patients face multiple medical decisions related to living with kidney failure. Given their frequent interaction with health services, patient participation may be of special value., Design: Qualitative design with a narrative approach., Methods: In 2018, eleven patients aged 35-64 years undergoing hospital haemodialysis participated in individual interviews. All interviews were analysed using a narrative approach. Reporting followed the Consolidated criteria for Reporting Qualitative Research guidelines., Findings: The patients' narratives of participation comprised three themes following their healthcare trajectory: Informed, but not involved in treatment choices; Duality of care and control; and Frail trust reflecting collaborative deficiencies. The patients received good information about dialysis, but were not involved in choice of treatment modality. Professional work, as well as the nature of treatment, contributed to restricted patient autonomy. Patients' trust suffered from collaborative deficiency generating delays in their treatment trajectories, and patients extended their responsibility into the coordination of transitions as a way of coping with these issues., Conclusions: The study identified challenges related to patient involvement and interdisciplinary collaboration. Involving patients through dialogue and acknowledging their experiences, preferences and lifestyles may strengthen the mutual patient-professional understanding of treatment. Despite increased focus on seamless trajectories, patients face obstacles regarding interdisciplinary collaboration and coordination of health services., Relevance to Clinical Practice: The findings indicate a want of individually customised care for people requiring dialysis. Patients need to be involved in the choice of treatment modality as well as decisions related to the current treatment. Information must include potential consequences of the different treatment modalities. Health services need to strengthen collaboration in order to secure treatment continuity and patient involvement., (© 2020 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Introduction: The aim of this study was to increase student empathy towards hemodialysis patients through an educational intervention that simulates a hemodialysis patient experience., Methods: Second-year pharmacy students (n = 83) in a required therapeutic module were asked to follow key lifestyle modifications of a hemodialysis patient for two weeks. Students' self-perceived empathy level was assessed using the Kiersma-Chen Empathy Scale (KCES) pre- and post-intervention and post-reflection questions captured students' perceptions of the experience. Data were analyzed using frequencies and Wilcoxon signed ranks tests to assess pre-post changes. Reflection questions were assessed using a grounded analysis to identify themes., Results: Significant differences were found on 13 of 15 KCES items and KCES composite scores. Of the 13 significant KCES items, nine were related to the cognitive domain and four were related to the affective domain. When asked how the experience impacted the student personally, 38 responded that it provided them with a better understanding of the challenges associated with managing hemodialysis treatments. In response to how this experience would change their professional interactions with a hemodialysis patient, students explained that they felt more equipped to empathize with patients (n = 22)., Conclusions: This intervention improved students' cognitive and affective empathy towards hemodialysis patients, which may prepare them to be more compassionate healthcare professionals. Experiencing first-hand some of the quality-of-life challenges hemodialysis patients face significantly influenced student empathy levels towards this population., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Patients undergoing hemodialysis experience pain and anxiety during needle insertion, and the scientific interest in aromatherapy in reducing pain and anxiety is increasing. Thus, this study aimed to determine the effects of sweet orange aromatherapy on pain and anxiety during needle insertion in hemodialysis., Design: Quasi-experimental, pretest, and posttest., Methods: This study was carried out among 50 patients with chronic kidney disease who were non-randomly assigned to either sweet orange aromatherapy or calm breathing in three outpatient hemodialysis centers in the Philippines between July and August 2015. The numeric rating scale and adapted state-trait anxiety inventory were utilized to measure pain and anxiety., Results: After the intervention, both the pain and anxiety scores were significantly lower for patients who received sweet orange aromatherapy than those who received calm breathing. The results obtained modest effect sizes that imply high practical significance., Conclusion: The sweet orange aromatherapy can be effective in reducing pain and anxiety. Thus, this can be used by nurses as an alternative and complementary approach to reduce both pain and anxiety in painful procedures like needle insertion., (© 2020 Wiley Periodicals, Inc.)

Purpose: Depression and impairment of quality of life (QoL) reduce the survival of individual on hemodialysis (HD). However, few studies evaluated the impact of these conditions on the survival of older patients undergoing HD., Methods: A retrospective cohort study was performed including patients aged ≥ 60 years on HD in Recife, Brazil, assessed in 2013 and monitored until 2017. Depression was evaluated with the Mini-International Neuropsychiatric Interview and QoL with the Control, Autonomy, Self-realization, and Pleasure Questionnaire (CASP-16). Survival differences according to the depression and QoL status were measured by Kaplan-Meier analysis and Cox regression. Death Certificates were analyzed to assess the cause of death., Results: A total of 171 patients were included (mean age 68.7 ± 6.9 years). The mean follow-up time was 3 years (maximum 4.5 years) and there were 98 deaths (57.3% of the sample). In a multivariate model that included depression and QoL, only QoL impairment was associated with a higher risk of death (HR 1.62, p = 0.035). Among CASP domains, only "Control" was associated with survival (HR 0.90, p = 0.014). Depression was unrelated to the cause of death, but there was a trend for death by endocrine diseases if QoL was impaired (p = 0.057)., Conclusion: QoL impairment is a key predictor of prognosis in older patients on HD and may be more important than depression. It is important that teams dealing with this population include in protocols an assessment of QoL, in order to offer a range of care according to the needs of these patients.

Objective: Depression and anxiety often coexist in patients with end-stage-kidney disease. Recently, studies showed that a composite 'general distress score' which combines depression and anxiety symptoms provides a good fit in dialysis and oncology patients. We aim to investigate if the three most frequently used self-report questionnaires to measure depression and anxiety in dialysis patients are sufficiently unidimensional to warrant the use of such a general distress score in two cohorts of dialysis patients., Methods: This study includes two prospective observational cohorts of dialysis patients (total n = 749) which measured depression and anxiety using Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI) and Hospital Anxiety and Depression Scale (HADS). Confirmatory factor analyses was used to investigate both a strictly unidimensional model and a multidimensional bifactor model that includes a general distress, depression and anxiety factor. The comparative fit index (CFI) and The Root Mean Square Error of Approximation (RMSEA) were used as model fit indices., Results: Factor analysis did not show a good fit for a strictly unidimensional general distress factor for both the BDI/BAI and HADS (CFI 0.690 and 0.699, RMSEA 0.079 and 0.125 respectively). The multidimensional model performed better with a moderate fit for the BDI/BAI and HADS (CFI 0.873 and 0.839, RMSEA 0.052 and 0.102)., Conclusions: This data shows that the BDI/BAI and HADS are insufficiently unidimensional to warrant the use of a general distress score in dialysis patients without also investigating anxiety and depression separately. Future research is needed whether the use of a general distress score might be beneficial to identify patients in need of additional (psychological) support., Competing Interests: Declaration of competing interest We have no conflict of interest to report. The OLVG hospital has full ownership of the data collected for this study., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Recently, it has been demonstrated that chronic inflammation could have a role on fatigue onset in chronic hemodialysis (HD). Research on neuro-immune interactions highlighted that an alteration of basal ganglia functioning, secondary to chronic inflammation, may translate in a reduced motivation and altered reward processes in chronic diseases. This study investigated a possible correlation between fatigue severity and reward mechanisms, that regulate motivational dispositions, in HD patients. Evaluation scales were administered to ninety-four patients on HD (54 Male, 40 Female; Md age  = 67±26.5; Dialytic Md age in years = 4±6.3. Fatigue was assessed by using Fatigue Severity Scale (FSS). Behavioural Inhibition System (BIS) and Behavioural Activation System (BAS) Scale was administered to investigate approach/avoidance behaviours. Anxiety and depression were measured by State-Trait Anxiety Inventory (STAI-Y) and Beck Depression Inventory (BDI-II). Results show that the distribution of HD patients for FSS score did not show a normal pattern. FSS score was significantly higher in patients with high BIS Z-score than in patients with low and medium BIS Z-score. BDI score and STAI-Y scores were similar among BIS Z-score groups of patients. Findings suggest that in patients on chronic hemodialysis there is a correlation between fatigue severity symptoms and motivational disposition mechanisms that predispose to action inhibition.

Background and Objectives: Although some patients regret the decision to start dialysis, modifiable factors associated with regret have rarely been studied. We aimed to identify factors associated with patients' regret to initiate dialysis., Design, Setting, Participants, & Measurements: A 41-item questionnaire was administered to adult patients receiving maintenance dialysis in seven dialysis units located in Cleveland, Ohio, and its suburbs. Of the 450 patients asked to participate in the study, 423 agreed and 397 provided data on decisional regret. We used multivariable logistic regression to identify predictors of regret, which was assessed using a single item, "Do you regret your decision to start dialysis?" We report adjusted odd ratios (ORs) and 95% confidence intervals (95% CIs) for the following candidate predictors: knowledge of CKD, attitudes toward CKD treatment, and preference for end-of-life care., Results: Eighty-two of 397 respondents (21%) reported decisional regret. There were no significant demographic correlates of regret. Regret was more common when patients reported choosing dialysis to please doctors or family members (OR, 2.34; 95% CI, 1.27 to 4.31; P <0.001). Patients who reported having a prognostic discussion about life expectancy with their doctors (OR, 0.42; 95% CI, 0.18 to 0.98; P =0.03) and those who had completed a living will (OR, 0.48; 95% CI, 0.25 to 0.95; P =0.03) were less likely to report regret with dialysis initiation., Conclusions: Dialysis regret was common in this sample. Demographic factors (age, sex, marital status, race, or educational attainment) were not significantly associated with regret, but modifiable care processes were., Podcast: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2020&#95;06&#95;09&#95;CJN13781119.mp3., (Copyright © 2020 by the American Society of Nephrology.)

Background: Chronic kidney disease (CKD) leads to decreased quality of life (QOL) by increasing the risk of death during the progression of its pathogenesis. However, many factors can be improved to support QOL. This study aimed to assess QOL among CKD patients in Nepal and to determine the factors associated with their QOL., Method: A cross-sectional study was used for data collection. CKD cases receiving medical attention in the Bir Hospital in Mahaboudh, Kathmandu; Tribhuvan University Teaching Hospital in Maharajgunj, Kathmandu; Sumeru Hospital in Dhapakhel, Lalitpur; and Shahid Dharma Bhakta National Transplant Centre in Bhaktapur between August and October 2019 were invited to participate in the study. A validated questionnaire and the kidney disease quality of life short form (KDQOL-SF™ 1.3) were used to assess QOL. A questionnaire was completed by the researcher in face-to-face interviews. Logistic regression was used to detect the associations between variables at the significance level of α = 0.05., Results: A total of 440 participants were recruited into the study: 56.59% were males, 74.32% were aged between 31 and 70 years, 25.68% were illiterate, and 82.95% were unemployed. The prevalence of good QOL among CKD in the domains of the physical component summary (PCS), mental component summary (MCS), and kidney disease component summary (KDCS) with and without hemodialysis were 53.64, 22.05, 21.28, and 13.19%, respectively. After controlling for all potential confounding factors, eight variables were found to be associated with good QOL in the domain of PCS: age, education, stage of CKD, hemodialysis, transporting oneself to a hospital, health insurance, medical expenses, and perceived lack of difficulty in handling medical expenses. Six variables were associated with good QOL in the domain of MCS after controlling for all potential confounding factors: residence, stage of CKD, transporting oneself to a hospital, health insurance, medical expenses, and perceived lack of difficulty in handling medical expenses., Conclusions: Public health interventions should be developed and implemented to improve QOL among CKD patients in Nepal by focusing on older female patients who have low education, live in rural areas and no health insurance.

Objective: End-stage renal disease (ESRD) leads to renal replacement therapy and certainly has an impact on patients' health-related quality of life (HRQoL). This study aimed to review and compare the HRQoL between peritoneal dialysis (PD) and hemodialysis (HD) patients using the 36-Item Short Form Health Survey (SF-36), EuroQoL-5-dimension (EQ-5D) and the Kidney Disease Quality of Life Instrument (KDQOL)., Methodology: Systematic review was conducted by identify relevant studies through MEDLINE and SCOPUS up to April 2017. Studies were eligible with following criteria: studied in ESRD patients, compare any pair of renal replacement modalities, and reported HRQoL. The unstandardized mean differences (USMD) of HRQoL among modalities were calculated and pooled using a random-effect models if heterogeneity was present, otherwise a fixed-effect model was applied., Results: A total of twenty-one studies were included with 29,000 participants. Of them, mean age and percent male were 48.1 years and 45.1, respectively. The pooled USMD (95% CI) of SF-36 between PD and HD (base) were 1.86 (0.47, 3.24) and 0.42 (- 1.99, 2.82) for mental component and physical component summary scores, respectively. For EQ-5D, the pooled USMD of utility and visual analogue scale (VAS) score were 0.02 (- 0.06, 0.10) and 3.56 (1.73, 5.39), respectively. The pooled USMD of KDQOL were 9.67 (5.67, 13.68), 6.71 (- 5.92, 19.32) 6.30 (- 0.41, 12.18), 2.35 (- 4.35, 9.04), 2.10 (0.07, 4.13), and 1.21 (- 2.98, 5.40) for burden of kidney disease, work status, effects of kidney disease, quality of social interaction, symptoms, and cognitive function., Conclusion: Patients with chronic kidney disease (CKD) stage 5 or ESRD treated with PD had better generic HRQoL measured by SF-36 and EQ-5D than HD patients. In addition, PD had higher specific HRQoL by KDQOL than HD patients in subdomain of physical functioning, role limitations due to emotional problems, effects and burden of kidney disease.

Depression may hamper the immune system and nutritional status, which leads to poor outcomes of treatment. It is very common in dialysis patients. There are the numbers of parameters affected by the depression of patients and available studies are not enough to define the association between biological parameters and depression in the dialysis population. The purposes of the study were to find the prevalence of depression and association of it with the biochemical abnormalities in the dialysis patients.The selected battery of tests (clinician-administered questionnaires) were applied to dialysis patients (test cohort, n = 298) and caregivers (control cohort, n = 202) for establishing depression. The demographic and clinical conditions of participants were also collected. Univariate analysis followed by multiple regression analysis was performed for demographical parameters, clinical conditions, and laboratory results for the detection of association of them with depression. The abnormal test considered as more than 2 SD of mean below the normal value. Out of all tests, at least 2 abnormal tests were considered as mild depression. More than half of abnormal parameters among all tests were considered as moderate depression and all abnormal parameters were considered as severe depression.There was a significant difference for all the test between dialysis patients and the caregivers (P < .0001 for all). The half (153 out of 298) of dialysis patients were depressive and clinically asymptomatic. 70 (23%) dialysis patients were mild depressive, 45 (15%) dialysis patients were moderate depressive, and 38 (13%) dialysis patients were severely depressive. Serum phosphate (P = .023), level of parathyroid hormone (P = .021), and urea reduction rate (P = .048) were directly associated with depression.Biochemical abnormalities (serum phosphate level, parathyroid hormone, and urea reduction rate) were independent predictors of depression in the dialysis population.Level of evidence: III.

Objective: This study aims to compare the effect of pure aerobic exercise and combined aerobic resistance exercise on dialysis adequacy and quality of life in patients on maintenance hemodialysis., Materials and Methods: A total of 45 patients on maintenance hemodialysis were divided into three groups: pure aerobic exercise group, combined aerobic resistance exercise group, and control group. Patients in the control group were only given the usual treatment, which included dietary guidance, drug therapy, and hemodialysis. The other training groups underwent 12-week exercise intervention therapy on the basis of the usual treatment. Blood samples were collected before and after the hemodialysis, at the beginning and end of the intervention for these three groups. Then, the blood urea nitrogen (BUN) concentration was determined, the urea clearance index (Kt/v) and urea degradation rate (URR) were calculated, the dialysis adequacy was evaluated, and the short form-36 (SF-36) scale was used to evaluate the life quality., Results: Before intervention, there was no significant difference in general health condition (GH), Kt/v, URR, SF-36 total score, and the score of each dimension in the three groups. After the intervention therapy, the Kt/v, URR, GH, vitality (VT), and SF-36 total score markedly improved in the pure aerobic exercise group, while the Kt/v, URR, GH, VT, physical functioning (PF), and SF-36 total score significantly increased in the combined aerobic resistance exercise group. Furthermore, compared with the pure aerobic exercise group, the improvement effect of body function (PF score) was better in the combined aerobic resistance exercise group., Conclusion: Both pure aerobic exercise and combined aerobic resistance exercise can significantly improve the dialysis adequacy and quality of life of maintenance hemodialysis patients. Compared with the pure aerobic exercise group, the effect of combined aerobic resistance exercise on PF was better.
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Introduction: Despite the well-known benefits of exercise during the pretransplantation and post-transplantation phases, adherence to active lifestyles is still reduced. The aim of the present study is to evaluate how many patients who have received organ transplants and candidates for organ transplantation carry out physical or sports activities in order to increase adherence to an active lifestyle., Methods: The patients who agreed to participate in the study were interviewed about their lifestyle habits by the staff at the nephrology, dialysis, and hepatology units of the Emilia-Romagna region. The interview investigated the patient's lifestyle (active or sedentary) and type of physical activity (walking, cycling, gardening, gym at least 3 to 40 minutes, 2 to 3 times per week) or sport (training > 2 times per week) routinely practiced., Results: We collected 1138 interviews from patients on the waiting list (n = 159) for organ transplant, those with kidney transplants (n = 756), and those with liver transplants (n = 223) monitored in the Emilia-Romagna hospitals (regional patients 67%, extraregional 33%). Eighty-four patients on the waiting list for a transplant (kidney) were sedentary, 75 practiced physical activity, and 10 of 75 physically active patients practiced sport. Four hundred fifteen patients with kidney transplants were sedentary, 341 practiced physical activity, and 31 of 341 physically active patients practiced sport. Among patients with liver transplants, 56 were sedentary, 167 practiced physical activity, and 20 of 167 physically active patients played sport., Conclusions: In-line with the general population, we confirmed a high tendency toward a sedentary lifestyle (44% of respondents) among patients with organ transplants and those on waiting lists for organ transplants. Including a prescription for physical exercise as part of the therapeutic regimen can be useful for changing lifestyles during the pre- and post-transplantation period., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Depression is common in patients on haemodialysis and associated with adverse outcomes. Antidepressant use is widespread though evidence of efficacy is limited., Objectives: To study antidepressant management practices in patients on haemodialysis with reference to NICE guidelines on management of depression in adults with chronic physical health problems., Design: Prospective, multicentre, longitudinal cohort study with 6-15 month follow-up., Participants: Patients on haemodialysis established on antidepressant medication., Measurements: Baseline assessment of mood was undertaken using Beck Depression Inventory (BDI-II). Demographic, clinical and medication data were also collected. Changes in clinical and life circumstances and medication during follow-up were recorded. At follow-up, BDI-II was reassessed and diagnostic psychiatric assessment undertaken., Results: Forty-one patients were studied. General practitioners were the main prescribers (68%). Ten agents were in use, the commonest being Citalopram (39%). Doses were often suboptimal. At baseline, 30 patients had high BDI-II scores (≥16) and 22 remained high at follow-up. Eleven had BDI-II < 16 at baseline. In five, this increased on follow-up to ≥16. Sixteen patients (39%) had no medication review during follow-up, 14 (34%) had a dose review, and 11 (27%) a medication change. On psychiatric assessment at follow-up, eight patients had current major depressive disorder (MDD), seven recurrent and 20 evidence of past MDD. Six displayed no evidence of ever having MDD., Conclusions: Antidepressant management in patients on haemodialysis reflected poor drug selection, overprescription, under-dosing and inadequate follow-up suggesting sub-optimal adherence to NICE guidelines. Most patients had high depression scores at follow-up. Antidepressant use in haemodialysis requires reappraisal., (© 2020 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Objective: Symptoms of anxiety are highly prevalent in dialysis patients and are associated with adverse clinical outcomes. Identifying symptom dimensions may help to understand the pathophysiology, improve screening and guide treatment. Currently, there are no data on symptom dimensions of anxiety in dialysis patients. This study aimed to identify the best fitting dimensional model for anxiety in dialysis patients and assess the association between symptom dimensions of anxiety and adverse clinical outcomes., Methods: This study is a prospective observational cohort study including patients from 10 urban dialysis centers between 2012 and 2017. Anxiety symptoms were measured using the self-reported questionnaire Beck Anxiety Inventory. Confirmatory factor analysis was used to identify symptom dimensions. The association between dimensions and mortality, hospitalization and quality of life was investigated using stepwise cox, poisson and lineair regression models. Multivariable models included demographic, social, laboratory and clinical variables to adjust for possible confounding., Results: In total 687 chronic dialysis patients were included. A Somatic and Subjective anxiety dimension were identified. Only Somatic anxiety symptoms showed an association with increased risk of hospitalization and mortality (Rate Ratio 1.73 (1.45-2.06) p = .007 and Hazard Ratio 1.65 (1.15-2.37) p = .007 respectively). These associations were independent from somatic comorbidity. All symptom dimensions of anxiety showed an association with Quality of Life., Conclusion: This study shows that anxiety is common in chronic dialysis patients and comprises of a somatic, subjective, and a total score. The discrimination between anxiety dimensions can be useful for clinical practice, as they are related to different clinical outcomes., Competing Interests: Declaration of Competing Interest We have no conflict of interest to report. The OLVG hospital has full ownership of the data collected for this study., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: To measure health-related and care-related quality of life among informal caregivers of older people with end-stage kidney disease (ESKD), and to determine the association between caregiver quality of life and care recipient's treatment type., Methods: A prospective cross-sectional study was conducted. Three renal units in the UK and Australia were included. Informal caregivers of people aged ≥75 years with ESKD managed with dialysis or comprehensive conservative non-dialytic care (estimated glomerular filtration (eGFR) ≤10 mL/min/1.73m 2 ) participated. Health-related quality of life (HRQoL) was assessed using Short-Form six dimensions (SF-6D, 0-1 scale) and care-related quality of life was assessed using the Carer Experience Scale (CES, 0-100 scale). Linear regression assessed associations between care-recipient treatment type, caregiver characteristics and the SF-6D utility index and CES scores., Results: Of 63 caregivers, 49 (78%) were from Australia, 26 (41%) cared for an older person managed with dialysis, and 37 (59%) cared for an older person managed with comprehensive conservative care. Overall, 73% were females, and the median age of the entire cohort was 76 years [IQR 68-81]. When adjusted for caregiver sociodemographic characteristics, caregivers reported significantly worse carer experience (CES score 15.73, 95% CI 5.78 to 25.68) for those managing an older person on dialysis compared with conservative care. However, no significant difference observed for carer HRQoL (SF-6D utility index - 0.08, 95% CI - 0.18 to 0.01) for those managing an older person on dialysis compared with conservative care., Conclusions: Our data suggest informal caregivers of older people on dialysis have significantly worse care-related quality of life (and therefore greater need for support) than those managed with comprehensive conservative care. It is important to consider the impact on caregivers' quality of life when considering treatment choices for their care recipients.

Aim: Maintenance hemodialysis (MHD) frequency is associated with survival and complication rates. Achieving the optimal balance between healthcare, quality of life (QOL), and medical costs is challenging. We compared complications, inflammatory status, nutritional status, and QOL between patients with different MHD frequencies., Material and Methods: This was a multicenter randomized trial of patients treated between May 2011 and August 2017 at 3 tertiary hospitals in Wenzhou. Patients were grouped according to their treatment schedule over 1 year: twice-weekly or 3-times-weekly. Complications, biochemistry parameters, and QOL (KDQOL-SFTM 1.3 scale) were assessed., Results: One hundred forty patients were included aged 29 to 68 years (mean age, 50.9 ± 4.3 years). There were no significant differences in infection, heart failure, or cerebral hemorrhage complications between the 2 groups (P = .664). Pre-dialysis hemoglobin, high-sensitivity C-reactive protein, serum albumin, total cholesterol, triglyceride, calcium, phosphate, parathyroid hormone, and ejection fraction were similar in both groups (P > .05). After 1 year of MHD, both groups exhibited significant improvements in these parameters (all P < .05) with no significant differences between groups. Serum creatinine, blood urea nitrogen (BUN), and weekly standard hemodialysis treatment adequacy did not improve after treatment (all P > .05), although a difference in BUN was observed between the 2 groups (P < .001). QOL was superior in the twice-weekly group than in the 3-times-weekly group (all P < .05), except for social support, which was slightly better in the 3-times-weekly group than in the twice-weekly group., Conclusions: Twice- and 3-times-weekly MHD resulted in comparable inflammatory and nutritional clinical outcomes and adverse events. QOL was better for the twice-weekly schedule. Even for patients with economic constraints, twice- or 3-times-weekly MHD should be selected with caution after consideration of BUN levels at baseline.

Recent technical advances have enabled the creation of mobile dialysis device prototypes. These prototypes have been tested for their ability to allow an individual to be dialyzed continuously rather than sporadically. The most recent prototype of a mobile dialysis device aims at increased functionality, which suggests that human factors issues (e.g., efficiency, bulkiness, and weight) are now considered carefully. This study describes advances in the design of an Ambulatory Kidney to Improve Vitality (AKTIV), using an interview protocol during the early stages of product development to capture patients' and caregivers' reactions. The AKTIV has the potential to improve patients' quality of life and decrease mortality rates. The goal of our study is to examine patients' and caregivers' design preferences and feature considerations for an AKTIV. We interviewed 22 participants (age M = 57.50, SD = 13.30), of whom 12 were female and 16 were patients. A pre-interview survey was distributed to the participants, and semi-structured interviews were subsequently held. The pre-interview results show that the belt and backpack designs were preferred over the shoulder bag and distributed designs. The participants also indicated on their pre-interview forms that safety and accuracy were more important to them than attachment ease, comfort, compactness, or operational simplicity. Invisibility and mobility were frequently mentioned when determining the strengths of each of the five design types during the interviews. Finally, individual differences in preferences for the various design types and attributes were identified. The results from our study have important implications for improving efficiency, effectiveness, and user satisfaction in relation to AKTIV prototypes and products. The findings from this interview study will help to ensure engineers and clinicians have target parameters for redesigning the AKTIV., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The aim of this study was to develop a patient on hemodialysis resilience scale and to verify validity and reliability. This patient on hemodialysis resilience scale (PHRS) was developed according to the scale development process by DeVellis (2017). Thirty-one publications on the subject were reviewed, and in-depth interviews with seven patients on hemodialysis were conducted. Items comprising the scale were reviewed and modified through evaluation by a panel of experts and face validity. For verification of validity, a content validity index for the items, exploratory factor analysis, and confirmatory factor analysis were performed. In the exploratory factor analysis, the PHRS was categorized into three factors: 'pursuing a positive meaning in life,' 'accepting hemodialysis as a part of daily life,' and 'building a willingness to live through meaningful relationships.', Competing Interests: The authors reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

Objective: This study evaluated the effects of melatonin supplementation on parameters of mental health, glycemic control, markers of cardiometabolic risk, and oxidative stress in diabetic hemodialysis (HD) patients., Design: A randomized, double-blind, placebo-controlled clinical trial was conducted in 60 diabetic HD patients, 18-80 years of age. Participants were randomly divided into 2 groups to take either melatonin (2 x 5mg/day) (n = 30) or placebo (n = 30) 1 hour before bedtime for 12 weeks. The effects of melatonin on mental health, metabolic status, and gene expression related to metabolic status were assessed using multiple linear regression adjusting for age and BMI., Results: Melatonin supplementation significantly decreased Pittsburgh Sleep Quality Index (P = .007), Beck Depression Inventory index (P = .001), and Beck Anxiety Inventory index (P = .01) compared with the placebo. Additionally, melatonin administration significantly reduced fasting plasma glucose (β = -21.77 mg/dL, 95% CI -33.22 to -10.33, P < .001), serum insulin levels (β = -1.89 μIU/mL, 95% CI -3.34 to -0.45, P = .01), and homeostasis model of assessment-insulin resistance (β = -1.45, 95% CI -2.10 to -0.80, P < .001), and significantly increased the quantitative insulin sensitivity check index (β = 0.01, 95% CI 0.007-0.02, P < .001) compared with placebo treated subjects. In addition, melatonin administration resulted in a significant reduction in serum high sensitivity C-reactive protein (β = -1.92 mg/L, 95% CI -3.02 to -0.83, P = .001) and plasma malondialdehyde (β = -0.21 μmol/L, 95% CI -0.36 to -0.06, P = .005); also, significant rises in plasma total antioxidant capacity (β = 253.87 mmol/L, 95% CI 189.18-318.56, P < .001) and nitric oxide levels (β = 2.99 μmol/L, 95% CI 0.71-5.28, P = .01) were observed compared with the placebo., Conclusion: Overall, melatonin supplementation for 12 weeks to diabetic HD patients had beneficial effects on mental health, glycemic control, inflammatory markers, and oxidative stress., (Copyright © 2019 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Dialysis treatment has evolved to enable children to live longer and transition to adulthood. Thus, the focus of care shifts to a consideration of pediatric patients' quality of life and psychosocial functioning across childhood, adolescence, and young adulthood. Despite well-documented concerns in various domains (including depression/anxiety, self-esteem and social functioning, behavior problems, and academic and cognitive functioning), limited literature exists regarding psychosocial guidelines for children and adolescents undergoing dialysis. This article aims to address this gap by providing a review of the pediatric literature examining psychosocial functioning in patients treated with dialysis, as well as recommendations for specific psychosocial concerns. Overall recommendations for care include screening for anxiety and depression, referral to pediatric psychologists for evidence-based intervention, utilization of child life specialists, opportunities to promote social functioning, neuropsychological evaluation and school programming, ongoing support in preparing for transition to adult care, and periodic measure of quality of life. Together, these suggestions promote a holistic approach to patient-centered care by supporting both physical and psychosocial well-being.

Aim and Objective: We investigated the correlation between the frailty status of maintenance haemodialysis (MHD) patients and psychosocial factors., Background: Varying degrees of frailty have been reported in MHD patients, which affect their quality of life., Design: We adopted a cross-sectional design in this study., Methods: Clinical data of 187 patients at our centre were collected from December 2017-June 2018 using a cross-sectional survey. Psychosocial factors were measured using the Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale, 10-item Connor-Davidson Resilience Scale (CD-RISC), Chronic Disease Self-Efficacy Scales and Perceived Social Support Scale. Frailty status was estimated using the fatigue, resistance, ambulation, illnesses and loss of weight (FRAIL) scale. Spearman's correlation and multiple logistic regression analysis were conducted to identify the risk factors for frailty. This study complied with the STROBE checklist., Results: Of 187 patients, 11 cases (5.9%) of frailty were identified. Patient's age, comorbidities, parathyroid hormone level, sleep quality and depression were positively correlated with frailty (p < .05), while psychological resilience and social support were negatively correlated with frailty (p < .05). Logistic regression analysis revealed four risk factors for frailty among MHD patients, including age (p = .004), comorbidities (p = .023), depression (p = .023) and sleep disorders (p = .029). Conversely, protective factors included high psychological resilience (p = .019) and social support (p = .039)., Conclusion: Among MHD patients, the risk factors for frailty included age, comorbidity, depression and sleep disturbance, whereas the protective factors included psychological resilience and social support., Relevance to Clinical Practice: Frailty is not only common among older patients, but also among people of all age groups suffering from chronic diseases. Therefore, it is important to consider the health status of MHD patients and adopt targeted nursing strategies to alleviate symptoms of frailty and improve physical condition by the following ways: postpone the progress of comorbidities, improve sleep quality, control the symptoms of depression, foster psychological resilience and facilitate support from social and family., (© 2020 John Wiley & Sons Ltd.)

Rationale & Objective: Elicitation and documentation of patient preferences is at the core of shared decision making and is particularly important among patients with high anticipated mortality. The extent to which older patients with incident kidney failure undertake such discussions with their providers is unknown and its characterization was the focus of this study., Study Design: Retrospective cohort study., Setting & Participants: A random sample of veterans 67 years and older with incident kidney failure receiving care from the US Veterans Health Administration between 2005 and 2010., Exposures: Demographic and facility characteristics, as well as predicted 6-month mortality risk after dialysis initiation and documentation of resuscitation preferences., Outcomes: Documented discussions of dialysis treatment and supportive care., Analytical Approach: We reviewed medical records over the 2 years before incident kidney failure and up to 1 year afterward to ascertain the frequency and timing of documented discussions about dialysis treatment, supportive care, and resuscitation. Logistic regression was used to identify factors associated with these documented discussions., Results: The cohort of 821 veterans had a mean age of 80.9±7.2 years, and 37.2% had a predicted 6-month mortality risk>20% with dialysis. Documented discussions addressing dialysis treatment and resuscitation were present in 55.6% and 77.1% of patients, respectively. Those addressing supportive care were present in 32.4%. The frequency of documentation varied by mortality risk and whether the patient ultimately started dialysis. In adjusted analyses, the frequency and pattern of documentation were more strongly associated with geographic location and receipt of outpatient nephrology care than with patient demographic or clinical characteristics., Limitations: Documentation may not fully reflect the quality and content of discussions, and generalizability to nonveteran patients is limited., Conclusions: Among older veterans with incident kidney failure, discussions of dialysis treatment are decoupled from other aspects of advance care planning and are suboptimally documented, even among patients at high risk for mortality., (Copyright © 2019 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.)

Objectives: Hemodialysis is the most used renal replacement modality for end-stage renal disease patients. Dialysis patients are usually assessed for quality of life (QoL) but smiling was never studied. Duchenne smile is a genuine expression of joy, associated with better survival in some groups of the general population. In this study, we aimed to evaluate whether the smile of dialysis patients can predict their QoL and mortality. Methods: All hemodialysis patients in Saint-George Hospital were included in this prospective study. Patients were interviewed using the Health-Related QoL questionnaire and followed for 10 days for smile screening. Those who smiled more than 34% of time were considered as smiling, then followed for death over 2 years. Results: Overall, 71 patients were studied. Duchenne smile was associated with death at 1 and 2 years (HR = 0.194 [95% CI 0.039-0.958], p = .044) but not with sex or diabetes. Smiling showed a statistically significant correlation with older age, fewer hospitalizations, vitality, physical component score, several QoL scores and general health. Conclusions: A simple observation of patients' Duchenne smile by nephrologists in hemodialysis units can give an idea about their QoL and 2-year survival.

Background: Chronic kidney disease is an increasingly common health problem for Aboriginal and Torres Strait Islander people. It is associated with multiple concurrent psychosocial stressors frequently resulting in negative impacts on emotional and social wellbeing. There is need for well-designed intervention studies to provide evidence of effective treatment for comorbid depression or other mental illness in this setting. Attention to early phase piloting and development work is recommended when testing complex interventions. This paper documents feasibility testing and adaptation of an existing culturally responsive brief wellbeing intervention, the Stay Strong App, and three commonly used wellbeing outcome measures, in preparation for a clinical trial testing effectiveness of the intervention., Methods: The Stay Strong App, which has not been used in the setting of Chronic Kidney Disease before, is reviewed and adapted for people with comorbid wellbeing concerns through expert consensus between research team and an Expert Panel. The outcome measures (Kessler 10, Patient Health Questionnaire 9, and EuroQoL) are valid, reliable, and commonly used tools to assess various aspects of wellbeing, which have also not been used in this context before. Feasibility and acceptability are examined and developed through 3 stages: Pilot testing in a purposive sample of five haemodialysis patients and carers; translation of outcome measures through collaboration between the Aboriginal Interpreter Service, Aboriginal and Torres Strait Islander research officers and the research team; and conversion of translated outcome measures to electronic format., Results: Research team and expert panel consensus led to adaptation of the Stay Strong App for renal patients through selective revision of words and images. Pilot testing identified challenges in delivery of the wellbeing measures leading to word changes and additional prompts, integration of audio translations in 11 local Indigenous languages within an interactive Outcome Measures App, and related research protocol changes., Conclusion: Modelling the complex intervention prior to full-scale testing provided important information about the design of both the outcome measures and the intervention. These changes are likely to better support success in conduct of the clinical trial and future implementation of the intervention in clinical settings.

Aim: Considering that exercise programmes are related with a range of benefits for end-stage renal disease patients, we evaluated the association between haemodialysis (HD) patients' involvement in intradialytic exercise training with the burden of their family caregivers., Methods: In this cross-sectional study, 60 caregivers of HD patients were recruited, 30 of them who cared for patients that regularly participated in an exercise programme during dialysis sessions and 30 caregivers who looked after patients undergoing usual HD treatment without intradialytic exercise. The caregivers were submitted to the Caregiver Burden Scale (CBS) and their quality of life (short-form-36 (SF-36)), anxiety and depression levels were assessed. Data were expressed as mean ± SD or median (interquartile range)., Results: Multiple linear regression showed that the global CBS score was significantly associated with the exercise training after adjusting for age, educational level and anxiety level of caregivers, and dependency level of patients measured by the Lawton scale (coefficient of determination = 0.53; adjusted coefficient of determination = 0.48). Additionally, the caregivers of HD patients submitted to intradialytic exercise (42.0 ± 12.9 years, 33.3% male) compared to caregivers of patients undergoing usual treatment (50.7 ± 17.5 years, 26.7% male) exhibited less caregiver burden (global CBS score = 1.2 (0.2) vs 1.9 (0.7), P < 0.001), better quality of life (physical component score = 53.7 (9.6) vs 49.7 (16.2) and mental component score = 50.6 (17.5) vs 28.2 (32.5), P < 0.05) and lower anxiety (7.2 ± 4.2 vs 10.8 ± 4.1, P = 0.001) and depression levels (3.0 (3.3) vs 6.0 (5.3), P = 0.034), respectively., Conclusions: Intradialytic exercise training in HD patients was associated with lower burden of their family caregivers., (© 2019 Asian Pacific Society of Nephrology.)

Objective: Depression is highly prevalent in hemodialysis patients, but few studies have evaluated older hemodialysis patients. The aim of this study was to evaluate the prevalence of depression, its associated factors and its impact on quality of life in an older population on hemodialysis., Methods: This was a cross-sectional study including 173 hemodialysis patients aged 60 years or older in Recife, Brazil. Depression was evaluated using the Mini-International Neuropsychiatric Interview when depressive symptoms (according to the 5-item Geriatric Depression Scale) were present. Quality of life was assessed with the Control, Autonomy, Self-realization and Pleasure Questionnaire (CASP-16). Data were also collected on sociodemographic, laboratory (albumin, parathormone, hemoglobin, and phosphorus) and dialysis (dialysis vintage, vascular access and hemodialysis adequacy) characteristics., Results: Depression was present in 22.5% of the sample. Depressed patients presented low CASP-16 quality of life scores (31.6 vs. 24.2, p < 0.001), twice the odds of albumin levels < 3.8 g/dL (OR 2.36; 95%CI 1.10-5.07; p = 0.027) and higher parathormone levels (OR 1.06; 95%CI 1.00-1.13; p = 0.05)., Conclusion: Older hemodialysis patients have a high prevalence of depression. Depressed patients presented poor quality of life, lower serum albumin and higher parathormone levels. Teams dealing with older hemodialysis patients should include depression and quality of life assessments in care protocols.

In recent years, nursing has come to be considered a high-risk and high-pressure profession, given the fast-paced working environment and constant need to handle emergencies, especially for nurses working in hemodialysis centers. Nearly every day, nurses are confronted with life and death situations and are required to provide skilled, high quality care for their patients, in fast-paced and demanding environments. Thus, nurses are susceptible to both psychological stress and other mental health problems, making them more vulnerable to burnout when compared against other healthcare professions.An anonymous online questionnaire was completed by a group of participating nurses, using the web-based survey platform WeChat. Registered nurses working in hemodialysis centers were randomly selected from 5 comprehensive tertiary level hospitals in Sichuan Province, China. The data collection instrument comprised two parts: demographic data and a nurse burnout questionnaire-the Maslach Burnout Inventory. Overall, 70 nurses were invited to participate, with 65 returning completed questionnaires, giving a response rate of 92.9%. In this survey, the burnout level was set at28.15 ± 12.39 for emotional exhaustion (EE), 10.23 ± 5.47 for depersonalization (DP), and 37.19 ± 8.31 for personal accomplishment (PA)-EE and DP levels are found to be high at the level of burnout.Job burnout was found to exist widely among the nurses of hemodialysis centers, which may then result in adverse effects on their physical and mental health. Active interventions can significantly reduce job burnout and also help maintain the stability of nursing workforce levels.

Patients with hemodialysis face many physical and emotional stressors; yet little is known regarding coping strategies and their effects on patients' quality of life (QOL) and anxiety and depressive disorders. A total of 117 patients were enrolled in this cross-sectional study between October 2016 and April 2017. This study assessed QOL (Medical outcome short form 36-MOS 36), coping (Assessment Scale for Coping Attitudes-COPE) and psychiatric comorbidities in hemodialysis patients. Beck Depression Scale and Beck Anxiety Scale were also applied. Differences between groups were evaluated using Student's t-tests and anova. Correlations among parameters were performed. Patients with any depressive disorder (22.2%, n = 26) and patients with any anxiety disorder (19.6%, n = 23) reported more impaired QOL. The most frequently used coping strategy in all patients was religious coping. Use of instrumental social support, humor, and positive reinterpretation scores were lower in patients with any depressive disorder (P = 0.009, P = 0.034, P = 0.047).The total score of emotion-focused coping strategies was lower with patients with any depressive disorder (P = 0.021) and emotion-focused coping strategies were positively correlated with QOL scores. Younger age and longer duration of hemodialysis have significant negative correlation with emotion-focused coping strategies' total score (P = 0.01, P = 0.02). Patients with hemodialysis use variety of coping strategies. The use of emotion-focused coping was associated with better QOL and reducing the risk of depressive disorder. Interventions to facilitate the use of adaptive coping strategies may improve patients' QOL and mood., (© 2019 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Background: Ineffective medical treatment could be avoided if patients had completed advance directives documents in advance. Aims: This study aimed to explore the predictors for the intentions of signing advance directives among dialysis patients. Methods: This cross-sectional study recruited 209 dialysis patients by using structured questionnaires. The Statistical Package for the Social Sciences (Version 17) (SPSS/IBM Inc., Chicago, IL, USA) was used for data analysis. Results: The predictors for the intention of signing the advance directives documents were having information on palliative care, the participants' knowing about the advanced directives documents, and their having more knowledge of advance care plans. Conclusions: Health care workers may strengthen the patient's knowledge of an "advance care plan" by health education during the dialysis treatment and provide information on websites for the patients. Impact statement: Hospital managers should train their staff to provide health teachings for an advance care plan.

Purpose: The waiting list period for kidney transplantation can be lengthy and associated with a deteriorated health-related quality of life (HRQoL). It might also be experienced differently depending on the experience of renal replacement therapy (preemptive or dialyzed patients), and the type of dialysis. The main objective of this study is to measure and compare HRQoL changes in preemptive, hemodialysis (HD), and peritoneal dialysis (PD) patients during the waiting list period for kidney transplantation., Methods: A sample of adult patients on kidney transplant waiting list from three French University Hospital centers was recruited. HRQoL was measured using the SF-36 and a specific questionnaire (ReTransQol), which were collected every 6 months before transplantation in preemptive, HD, and PD patients. Mixed-effects models taking into account time and possible confounding factors were used to compare HRQoL changes between the three groups., Results: Preemptive (n = 230), HD (n = 177), and PD patients (n = 39) were enrolled. The renal replacement therapy modalities, time (time on waiting list and age at registration), and gender were associated with HRQoL changes. The HD and PD patients had a significantly lower perceived HRQoL on Role Physical, Social Functioning, and Role Emotional dimensions than the preemptive patients, with lower scores for PD compared to HD patients. The HRQoL scores of all patients were lower compared to the French general population for all dimensions., Conclusions: A better understanding of pre-transplantation patients' experience can help improving patient care with adapted educational programs and psychological support depending on the type of renal replacement therapy.

Objective: To produce a transcultural adaptation of the Thirst Distress Scale (TDS) into Brazilian Portuguese and analyze the scale's psychometric properties for patients on hemodialysis (HD)., Methods: The original scale was translated, back translated, and discussed with psychometric assessment experts. The final version was tested with 126 patients on HD and retested with 70 individuals from the original patient population. Cronbach's alpha was used to measure the scale's internal consistency. Reliability of thirst intensity evaluated via the visual analogue scale (VAS) was tested with Kappa statistic and the Bland-Altman plot. Reproducibility was assessed based on the intraclass correlation coefficient (ICC)., Results: The wording of three items and the verb tenses of six had to be adjusted in the final version of the Brazilian Portuguese TDS. Comprehension of the scale by patients on HD was good, the scale's internal consistency was satisfactory (0.84; p<0.001), agreement with a visual analogue scale (VAS) was moderate (kappa=0.44; p<0.001), and reproducibility neared perfection (ICC=0.87; p<0.001)., Conclusion: Our results showed that the Brazilian Portuguese version of the scale might be used reliably. The Brazilian Portuguese version of the TDS is a practical, affordable, accessible and well-accepted tool that has a lot to offer for the management of patients with HD.

Background: End-stage kidney disease (ESKD) patients are living longer, often into older age, and commonly pursue kidney transplantation. Successful aging, a multidimensional construct of physical and social wellbeing, has been expanded and adapted for patients with chronic disease. However, perceptions of, barriers to, and experiences with successful aging among adults with ESKD are unclear and likely differ based on whether they have received a kidney transplant., Methods: Ten focus groups were held with 39 total ESKD patients aged ≥50 years (19 transplant candidates, 20 transplant recipients). Transcriptions were analyzed thematically by 2 independent coders using an inductive, constant comparative approach., Results: The mean age was 64.8 (SD = 7.5); 51% were African American and 64% were males. Six themes were identified: familiarity with successful aging, perceptions of successful aging after ESKD diagnosis, barriers to successful aging, experiences with successful aging among transplant candidates, experiences with successful aging among transplant recipients, and suggested interventions. While all participants sought to achieve successful aging while living with ESKD, experiences with successful aging differed between candidates and recipients. Candidates struggled with the limitations of dialysis; some viewed transplantation as an opportunity to age successfully, while others were resigned to the drawbacks of dialysis. In contrast, transplant recipients were optimistic about their ability to age successfully, believing their transplant facilitated successful aging. Participants believed support groups for adults with ESKD and more thoughtful health care for aging adults would promote successful aging., Conclusions: Adults with ESKD may benefit from discussions with their clinicians and caregivers about goals, barriers, and strategies regarding successful aging.

Objetives: To analyze depression, cognition, and physical function change in older adults on hemodialysis at 12-month follow-up, depending on frailty status., Design: Ongoing cohort study., Participants: 117 patients older than 69 years on hemodialysis; 75 men., Measurements: Frailty was measured with the frailty phenotype, disability in basic and instrumental activities of daily living with the Barthel and Lawton index respectively, physical function with the Short Physical Performance Battery (SPPB), cognitive status with the Mini Cognitive Examination, and depression with the Yesavage´s Geriatric Depression Scale (GDS), at hemodialysis initiation and after 12-month follow-up. Inflammatory and nutrition profile was determined with C-reactive protein (CRP), albumin, and haemoglobin levels., Results: The mean age of the participants was 78.1 years; 63 (53.8 %) were frail. Frail participants had a higher 12-month mortality risk compared to the non frail ones, hazard ratio 2.6 (95 % CI 0.9-7.9). Frail 12-month survivors presented an improvement in median GDS scores (10 to 9; p = .009). There was no change in frail survivors from SPPB ≤ 6 to SPPB > 6 and a shift in 29.3 % of non-frail survivors from SPPB > 6 to SPPB ≤ 6 (p = .007) after 12-month follow-up. Median CRP and haemoglobin levels improved in frail 12-month survivors from 13.9 to 8.3 mg/dL (p = .019) and 9.9-11.1 g/dL (p < .001) respectively., Conclusions: Frail older adults that initiate hemodialysis present higher mortality than the non-frail ones at 12-month follow-up. Frail patients that survive improve physical function, depression and inflammatory profile compared to the non frail ones., Competing Interests: Declaration of Competing Interest There are no conflicts of interest of any of the authors., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Background and Objectives: Few studies have investigated the role psychological inflexibility (PI) could have in the context of chronic renal failure. The primary objective of this study was to analyse the psychometric features, the reliability and the validity of the Spanish version of the Acceptance and Action Questionnaire-II (AAQ-II) adapted to the context of patients undergoing haemodialysis (HD). The secondary objective was to assess the relationship between PI and parameters related to the adherence to treatment and quality of life in these types of patients., Materials and Methods: Prospective cross-sectional study with patients on haemodialysis (n=186)., Results: The fat tissue index (15.56±5.72 vs. 18.99±8.91, P=.033), phosphorus levels (3.92±1.24 vs. 4.66±1.38; P=.001) and interdialytic weight gain (1.56±0.69 vs. 1.89±0.93, P=.016) were higher in patients with a higher PI score. Phosphorus levels (P=.013) significantly explained the variability of PI levels. PI was also shown as a significant predictor (P=.026) of the variability of phosphorus levels., Conclusions: The adaptation of the AAQ-II questionnaire to the HD context led to a valid and reliable measurement of PI in these types of patients and our results also seem to support the relationship between PI and health and quality of life parameters in patients with chronic conditions., (Copyright © 2019. Published by Elsevier España, S.L.U.)

Patients receiving hemodialysis treatment may experience several symptoms at the same time, such as fatigue and pain. Progressive relaxation exercises (PRE) have been reported to have positive effect on the control of these symptoms. In this study, a randomized, controlled, and experimental study was conducted to examine the effect of PRE on pain, fatigue, and quality of life in hemodialysis patients; the study was carried out with 48 intervention and 48 control patients receiving treatment in the hemodialysis units of 2 hospitals. Data were collected by a questionnaire prepared by the researcher, which included questions about sociodemographic variables and the disease; Piper Fatigue Scale; Visual Analog Scale that measures pain severity; and SF-36 Quality of Life Scale. The results of study revealed that mean total fatigue score and mean pain score decreased in the intervention group after the application of PRE; whereas no change was observed in the control group (P < .05). It was also found that quality of life physical component mean score and mental component mean score increased in the intervention group after the application of PRE (P < .05).

For immigrant chronic dialysis patients, religious behavior and religious coping may have a different impact on depressive symptoms compared to native patients. This study aims to describe both cross-sectional and longitudinal associations between religious behavior and coping with symptoms of depression for 281 native and 277 immigrant dialysis patients in the Netherlands. A higher prevalence of depressive symptoms was found in immigrant compared to native patients (49% vs. 36%). No significant cross-sectional or longitudinal associations were found in both groups between religious behavior and positive religious coping with depressive symptoms. Strong significant cross-sectional associations were found between negative religious coping items and depressive symptoms in both groups, while no longitudinal associations were found. So, similar impact of religiousness on the presence of depressive symptoms was found for both native and immigrant dialysis patients. Therefore, these results do not explain the higher prevalence of depressive symptoms found in immigrant chronic dialysis patients compared to native patients.

Background: Elevated serum uric acid (SUA) has been associated with vascular cognitive impairment (CI) in the elderly. However, its relationship with cognitive function in the elderly patients receiving maintenance hemodialysis (MHD) has not yet been elucidated., Objective: The cognitive impairment is prevalent in MHD patients. Various insults may contribute to cognitive impairment in patients with MHD. The aim of this study was to investigate the relationship between SUA and CI in the elderly patients receiving MHD., Methods: A total of 180 elderly MHD subjects from two hospitals were enrolled in our study. Cognitive function domains were evaluated by MMSE at the beginning of the trial. Demographic and clinical characteristics were collected and recorded., Results: The subjects were stratified into quartiles according to SUA level. Demographic and clinical characteristics such as age, gender, smoking habit, education year, blood pressure (BP), hemoglobin, albumin, blood glucose (BG), total cholesterol (TC), triglycerides (TG), high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), blood urea nitrogen (BUN), and serum creatinine (Scr) did not differ dramatically among groups (p > .05). The Q1 group showed the highest MMSE scores, and the Q4 group showed the lowest MMSE sores (p < .05). There was a negative correlation between SUA and MMSE scores (r = -.307, p = .014), and this correlation was independent of demographic and clinical characteristics., Conclusions: Elevated SUA maybe contributes to CI in the elderly MHD patients. SUA level is independent risk for the CI in the elderly MHD patients., (© 2020 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.)

Objectives: Fatigue is common and debilitating among dialysis patients. The aim of this study was to understand the longitudinal trajectory of fatigue and consider sociodemographic, clinical, and psychological factors that are related to variation in fatigue levels over time., Design: A prospective study of fatigue with yearly assessments over 3 years among prevalent in-centre haemodialysis (HD) patients., Methods: Fatigue severity was measured using the Chalder Fatigue Questionnaire and fatigue-related functional impairment using the Work and Social Adjustment Scale. The trajectories of fatigue outcomes were examined using piecewise growth models, using length of time on dialysis as time. Sociodemographic, clinical, and psychological predictors of fatigue were assessed using linear growth models, using follow-up time., Results: One hundred and seventy-four prevalent HD patients completed baseline measures, 118 at 12 months, 84 at 24 months, and 66 at 36 months. Fatigue severity scores decreased by 0.15 each year. Fatigue-related functional impairment increased by 1.17 each year. In adjusted linear growth models, non-white ethnicity was a significant predictor of lower initial fatigue severity (B = -2.95, 95% CI -5.51 to -0.40) and a greater reduction in fatigue severity of 1.60 each year (95% CI 0.35-2.36). A one-point increase in damage beliefs was associated with a 0.36 increase in fatigue-related functional impairment each year (95% CI -0.61 to -0.01)., Conclusion: Damage beliefs predicted an increase in fatigue-related functional impairment over time. However, the data strongly suggested that fatigue outcomes vary by length of time on dialysis. Statement of contribution What is already known on this subject? At least 1 in 2 haemodialysis (HD) patients are clinically fatigued. Growing evidence is available on the important role of psychological factors in fatigue across chronic conditions. The contribution of psychological factors, beyond distress, to fatigue in HD has not been examined to date. What does this study add? Ethnicity played a role in the initial level of fatigue severity and over time. Damage beliefs predicted an increase in fatigue-related impairment over time. Data strongly suggested that fatigue outcomes vary by length of time on dialysis., (© 2019 The Authors. British Journal of Health Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society.)

The objective of this study was to explore the impact of three early phases of renal dialysis, namely pre-dialysis, starting dialysis, and establishing dialysis, on dyadic relationships. Twenty UK-based dyads (20 male patients and their female partners) participated in semi-structured interviews and discussed the effects of dialysis on themselves and their relationship. Dyadic thematic analysis, facilitated by dyadic-level charting, integrated participants' experiences and enabled identification of patterns across dyads. We found that dialysis had positive and negative influences on identity, social relationships, and mental health, forming the themes: Prioritizing the Patient, Carrying the Burden , and Changing Identities. The final theme, Managing the Relationship , described how dyads prevented dialysis from negatively impacting their relationship. Dyadic-level charting provided a systematic examination of individual and dyadic experiences. These findings indicate that access to informational and support services for dyads as they prepare to start dialysis may minimize negative effects on their relationship.

Spirituality is an important part of practice of the healthcare providers. Spiritual therapy is important for patients with chronic and end-stage diseases such as end-stage renal disease due to changes in physical, mental, social and spiritual needs. Promotion of spiritual well-being, self-esteem and self-efficacy is very important for these patients. The aim of this study was to determine the effectiveness of spiritual therapy on spiritual well-being, self-esteem and self-efficacy in patients on hemodialysis. The quasi-experimental research design was pre-posttest with the control group. The statistical population was the patients on hemodialysis in Governmental Hospital of Shahid Mostafa in Ilam, Iran, in 2015. Twenty-four patients were entered to the study by convenience sampling. They were divided into experimental and control groups randomly. Twelve 60-min sessions of spiritual therapy were held for the experimental group twice a week. The tools included spiritual well-being scale of Paloutzian and Ellison, Self Esteem Inventory of Cooper Smith and Self-Efficacy Scale of Sherer. Data were analyzed by SPSS software through descriptive and inferential statistics (analysis of covariance). p Values < 0.05 were considered significant. Results indicated that the scores in the experimental group changed in spiritual health from 39.32 ± 3.38 to 43.40 ± 2.82, in self-esteem from 42.65 ± 2.61 to 45.90 ± 3.88 and in self-efficacy from 40.99 ± 2.19 to 44.65 ± 2.58 which was significant compared with the control group (p = 0.01). Spiritual therapy can be used as an effective intervention to improve spiritual well-being, self-esteem and self-efficacy in patients on hemodialysis. This intervention is directed to holistic care. It can be done by interdisciplinary participation in caring and psychological teams.

Aims and Objectives: This study aimed to construct and verify a model that explains and predicts the health-related quality of life in patients undergoing haemodialysis., Background: Individual and disease-related characteristics, social support, physical and emotional symptoms, patient role adherence and perceived health status may be interrelated and might affect the health-related quality of life of patients undergoing haemodialysis directly or indirectly., Design: A correlational, cross-sectional research design was used., Methods: Participants were 202 patients undergoing haemodialysis at one of the seven nephrology clinics specified in this study. A structured questionnaire was used to collect data from September-November 2017. The collected data were analysed using spss version 25.0 ® and amos 23.0. This study adhered to the STROBE guideline., Results: The hypothetical model with 13 of the 15 analysed paths showed a good fit to the empirical data: χ 2  = 85.67 (p < .001), normed χ 2  = 2.14, GFI = 0.94, CFI = 0.97, NFI = 0.94, TLI = 0.94, RMSEA = 0.08, and RMSR = 0.04. Symptoms (fatigue, quality of sleep, and depression), environmental (social support) and individual (age) characteristics and general health perception had a direct effect on health-related quality of life. Additionally, individual and environment characteristics affected health-related quality of life through biological functions, symptoms, functional status and general health perception. These variables explained 78.6% of the variation in health-related quality of life., Conclusions: To improve health-related quality of life in patients undergoing haemodialysis, systematic and integrated intervention programmes need to be developed and applied considering a variety of factors related to health-related quality of life., Relevance to Clinical Practice: Individual and environment characteristics, biological functions, symptoms, functional status and general health perception should be systematically monitored to improve the health-related quality of life of patients on haemodialysis. It is also necessary to develop detailed interventions that consider all these factors., (© 2019 John Wiley & Sons Ltd.)