Clinical and psychosocial factors predicting health‐related quality of life in hemodialysis patients

Many patients with end‐stage renal disease have significant impairment in health‐related quality of life (HRQoL). Most previous studies have focused on clinical factors; however, quality of life can also be affected by psychosocial factors. The aim of this study was to identify the possible predictors of HRQoL among clinical and psychosocial factors in hemodialysis (HD) patients. The study included 101 patients who were undergoing HD. Psychosocial factors were evaluated using the Hospital Anxiety and Depression Scale, Multidimensional Scale of Perceived Social Support, Montreal Cognitive Assessment, and Pittsburgh Sleep Quality Index. We also assessed laboratory and clinical factors, including albumin, Kt/V as a marker of dialysis adequacy, normalized protein catabolic rate, and duration of HD. The Euro Quality of Life Questionnaire 5‐Dimensional Classification (EQ‐5D) was used to evaluate HRQoL. The mean EQ‐5D index score was 0.704 ± 0.199. The following variables showed a significant association with the EQ‐5D index: age (P < 0.001), depression (P < 0.001), anxiety (P < 0.001), support from friends (P < 0.001), cognitive function (P < 0.001), duration of HD (P = 0.034), triglyceride (P = 0.031), total iron‐binding capacity (P = 0.036), and phosphorus (P = 0.037). Multiple regression analysis showed that age (95% confidence interval [CI] ?0.008 to ?0.002), anxiety (95% CI ?0.025 to ?0.009), and support from friends (95% CI 0.004 to 0.018) were independent predictors of impaired HRQoL. This study explored determinants of impaired HRQoL in HD patients. We found that impaired HRQoL was independently associated with age, anxiety, and support from friends. We should consider psychosocial as well as clinical factors when evaluating ways to improve HRQoL in HD patients.     

Attitudes toward stress and coping among primary caregivers of patients undergoing hemodialysis: A Q‐methodology study

Introduction Hemodialysis (HD) causes many life changes, not only for patients undergoing it but also for their families by allowing them to rely on this lifesaving equipment unless they receive a kidney transplant. The stress of the primary caregivers, who spends the most time in the family taking care of the patient undergoing HD, is quite high. This study was to identify attitudes about stress and coping among primary caregivers of HD patients. Methods Q‐methodology was undertaken because it integrates quantitative and qualitative research methods. A convenience sample of 33 primary caregivers of HD patients participated. Forty selected Q‐samples were obtained from each participant and were classified into a forced normal distribution using a nine‐point grid. Data was analyzed using a pc‐QUANL program. Findings Three discrete factors emerged as follows: Factor I (they reduced their stress by participating in religious activities; religious sublimation), Factor II (they always worried about the caregiving situations and about the patients' conditions; nervousness), and Factor III (they thought it better to accept their stressful situations; leading handler). Three factors accounted for 44.5% of all the variance, including Factor I (26.0%), Factor II (10.1%), and Factor III (8.4%). The eigenvalues were 8.58, 3.34, and 2.79, respectively. Discussion The subjectivities of the three factors that were identified can be applied during the planning stages of effective interventions for stress and coping. Healthcare workers in clinical practices should consider assesses primary caregivers' attitudes about stress and coping and approaches their situation to cope with it and to adapt to lifestyle changes.     

Health-related qualıty of lıfe, sleep qualıty, and depressıon in peritoneal dialysis and hemodıalysıs patıents

Health-related quality of life (HRQoL) and sleep quality (SQ) were impaired in patients with end-stage renal disease (ESRD). The impairment of both HRQoL and SQ and being in a depressive mood were found to be associated with increased morbidity and mortality in dialysis patients. We aimed to investigate the association between SQ, HRQoL, and depression, and to define independent predictors of SQ and depression in peritoneal dialysis (PD) and hemodialysis (HD) patients. Ninety HD patients (41 females, 49 males with mean age 50 ± 15.7 years) and 64 PD patients (27 females, 37 males with mean age 52.4 ± 15.3 years) receiving renal replacement therapy for at least 3 months were screened for the assessment of SQ, HRQoL, and depression in this cross-sectional study. A modified postsleep inventory, Short Form of Medical Outcomes Study (SF-36) and Beck depression inventory (BDI) were applied to all patients for evaluating SQ, HRQoL, and depression, respectively. HD and PD patients had similar total SQ scores. Physical and mental component scale of HRQoL were found to be significantly higher in HD patients (p < 0.001). PD patients were found to be much more in depressive mood when compared with HD patients (p < 0.001). Independent predictors of depression in patients were mental component scale of HRQoL, gender (being female), and dialysis modality (being PD patient). Physical component scale was also found to be an independent predictor of SQ. This study showed that despite similar SQ scores between two groups, HD patients had better HRQoL and less depression than PD patients.     

Religiousness, mental health, and quality of life in Brazilian dialysis patients

Patients with chronic kidney disease often use religion as a coping strategy to relieve suffering and serve as a source of strength. The aim of this study was to identify religious aspects associated with mental health and quality of life in Brazilian dialysis patients. A cross-sectional study was performed involving two dialysis centers in Brazil. Patients were selected consecutively over three typical dialysis treatment days. The questionnaire was self-administered and covered the following aspects: socio-demographic aspects, religiousness (using the Portuguese version of the Private and Social Religious Practice Scale), quality of life (World Health Organization Quality of Life brief Scale Brief Version), depression and anxiety (Beck Inventory), and pain grade. For statistical analysis, the hypothesis that different religious variables are associated (positively or negatively) with depressive/anxiety symptoms and quality of life in these patients was tested using linear regression, controlling for confounding variables. A total of 205 patients were invited to participate and 133 (64.8%) agreed to fill out the questionnaire. On the adjusted model, reading religious literature was found to be inversely associated with depressive symptoms (P < 0.001). In addition, the psychological domain of quality of life was positively associated with an increase in patient religiosity (P = 0.030) and greater religious importance for recovery from their dialysis condition (P = 0.016), whereas the environmental domain was positively associated with greater religious importance for recovery (P = 0.032). No religious aspects were associated with anxiety symptoms. Religiousness is associated with less depressive symptoms and better quality of life in Brazilian dialysis patients. Nephrologists should evaluate the patient's spirituality and religion in order to provide more integrative care.     

Self‐perceived quality of sleep and mortality in Norwegian dialysis patients

Sleep complaints are prevalent and associated with poor health‐related quality of life (HRQoL), depression and possibly mortality in dialysis patients. This study aimed to explore possible associations between sleep quality, daytime sleepiness and mortality in dialysis patients. In this study, 301 dialysis patients were followed up to 4.3 years. HRQoL was evaluated at baseline with the Kidney Disease and Quality of Life—Short Form (KDQoL‐SF), depression with Beck Depression Inventory (BDI), sleep quality with Pittsburgh Sleep Quality Index and daytime sleepiness with Epworth Sleepiness Scale. The single item “on a scale from 0–10, how would you evaluate your sleep?” in the sleep subscale in KDQoL‐SF was used to identify poor (0–5) and good sleepers (6–10). A total of 160 patients (53.3%) were characterized as poor sleepers. They were younger (r = 0.241, P < 0.001), had more depression (BDI: 8.72 ± 6.79 vs. 13.60 ± 8.04, P < 0.001), a higher consumption of hypnotics and antidepressants and reduced HRQoL (Mental Component Summary score: 45.4 ± 11.0 vs. 50.0 ± 10.4, P < 0.001. Physical Component Summary score: 35.0 ± 9.9 vs. 38.5 ± 10.5, P = 0.004). In multivariate analyses, poor sleepers had nearly a twofold increase in mortality risk (hazard ratio [HR] 1.92, confidence interval [CI] 1.10‐3.35, P = 0.022). Daytime sleepiness was not related to mortality (HR 1.01, CI 0.95‐1.08, P = 0.751). Sleep complaints predicted increased mortality risk in dialysis patients and should therefore be routinely assessed. Further studies are needed to find suitable treatment options for poor sleep in dialysis patients as it may affect both HRQoL and survival.     

Correlation between coping style and quality of life among hemodialysis patients from a low‐income area in Brazil

Quality of life (QOL) is an important outcome among end‐stage renal disease patients and can be associated with modifiable behaviors. We analyzed the correlation between coping style and QOL among hemodialysis patients. We studied 166 end‐stage renal disease patients undergoing hemodialysis. They were older than 18 years, under hemodialysis for at least 3 months, and had never received a transplant. Quality of life was assessed by SF‐36 and coping style was scored by the Jalowiec Coping Scale. Emotion‐oriented coping and problem‐oriented coping scores were compared according to sex, comorbidity, and socioeconomic status by the Mann‐Whitney test. Correlations between QOL and 2 coping styles (emotion‐oriented coping and problem‐oriented coping) were adjusted for age, time on dialysis, hemoglobin, creatinine, albumin, calcium–phosphorus product, and Kt/V by backward stepwise linear regression. There was no difference between coping scores according to sex, comorbidity, and socioeconomic status. Emotion‐oriented coping was independently and negatively associated with 4 QOL dimensions: physical functioning, role‐physical, role‐emotional, and mental health. Our results indicate that patients with high emotion‐oriented coping scores should be seen at risk for poor QOL. Patient education in coping skills may be used to change the risk of poor QOL.     

Barriers,biases, and beliefs about arteriovenous fistula placement in children: A survey of the International Pediatric Fistula First Initiative (IPFFI) within the Midwest Pediatric Nephrology Consortium (MWPNC)

There has been recent emphasis on increased arteriovenous fistula (AVF) use and decreased central venous catheter use in hemodialysis (HD) patients. The International Pediatric Fistula First Initiative was founded via collaborative effort with the Midwest Pediatric Nephrology Consortium to alert nephrologists, surgeons, and dialysis staff to consider fistulae as the best access in pediatric HD patients. A multidisciplinary educational DVD outlining expectations and strategies to increase AVF placement and usage in children was created. Participants were administered a survey previewing and postviewing to identify barriers to placement and usage of AVF in children. A total of 52 surveys were subdivided as either “dialysis staff” or “proceduralist” at five centers. Thirty‐three percent of respondents were unaware if their practice was following published guidelines. Sixty‐five percent of respondents stated they referred to a dedicated vascular access surgeon at their respective institutions. Methods used to monitor AVF function included physical exam, venous pressure monitoring, and ultrasound dilution. Vascular access was placed within 3 months in only 35% of patients. Interdisciplinary communication problems between surgeons, interventional radiologists, and nephrologists were identified as a major barrier. Lack of AVF usage was often due to maturation failure. Routine access rounds did not occur in any centers. Regarding monitoring, 74% of the respondents use physical exam, 26% use venous pressure monitoring, and 9% use ultrasound dilution. Ninety‐three percent of dialysis staff stated they would change practice patterns following the intervention; however, 12% of surgeons stated they would alter practice patterns. To our knowledge, this is the first report to identify barriers to placement of AVF in children from the perspectives of multidisciplinary team members including pediatric nephrologists, surgeons, interventional radiologists, and multidisciplinary dialysis staff.     

Longitudinal associations of depressive symptoms and pain with quality of life in patients receiving chronic hemodialysis

Depressive symptoms and pain are common in patients on chronic hemodialysis (HD), yet their associations with quality of life (QOL) are not fully understood. We sought to characterize the longitudinal associations of these symptoms with QOL. As part of a trial comparing two symptom management strategies in patients receiving chronic HD, we assessed depressive symptoms using the Patient Health Questionnaire‐9 (PHQ‐9), and pain using the Short Form McGill Pain Questionnaire (SF‐MPQ) monthly over 24 months. We assessed health‐related QOL (HR‐QOL) quarterly using the Short Form 12 (SF‐12) and global QOL (G‐QOL) using a single‐item survey. We used random effects linear regression to analyze the independent associations of depressive symptoms and pain, scaled based on 5‐point increments in symptom scores, with HR‐QOL and G‐QOL. Overall, 286 patients completed 1417 PHQ‐9 and SF‐MPQ symptom assessments, 1361 SF‐12 assessments, and 1416 G‐QOL assessments. Depressive symptoms were independently and inversely associated with SF‐12 physical HR‐QOL scores (β = ?1.09; 95% confidence interval [CI]: ?1.69, ?0.50, P < 0.001); SF‐12 mental HR‐QOL scores (β = ?4.52; 95% CI: ?5.15, ?3.89, P < 0.001); and G‐QOL scores (β = ?0.64; 95%CI: ?0.79, ?0.49, P < 0.001). Pain was independently and inversely associated with SF‐12 physical HR‐QOL scores (β = ?0.99; 95% CI: ?1.30, ?0.68, P < 0.001) and G‐QOL scores (β = ?0.12; 95%CI: ?0.20, ?0.05, P = 0.002); but not with SF‐12 mental HR‐QOL scores (β = ?0.16; 95%CI: ?0.050, 0.17, P = 0.34). In patients receiving chronic HD, depressive symptoms and to a lesser extent pain, are independently associated with reduced HR‐QOL and G‐QOL. Interventions to alleviate these symptoms could potentially improve patients' HR‐QOL and G‐QOL.     

Plasma myeloperoxidase,NT‐proBNP,and troponin‐I in patients on CAPD compared with those on regular hemodialysis

Myeloperoxidase (MPO) is a hemoprotein that is released during inflammation and may lead to irreversible protein and lipid modification, increasing levels of oxidized low density lipoprotein, and promoting athrogenesis. Recently, it has been considered as a risk factor for cardiovascular diseases. Similarly, the measurement of carotid intima‐media thickness gives an indication about the degree of atherosclerosis and prediction of clinical cardiovascular events. Elevated white blood cells counts may indicate a state of acute inflammation and follow its progression. Dialysis patients are at a high risk of developing cardiovascular disease compared with healthy subjects. The role of N‐terminal pro‐brain natriuretic peptide and increased cardiac troponin in identification and prognostication of cardiovascular diseases in end‐stage renal disease patients has been investigated. The current study aimed to evaluate plasma MPO and its possible relationship with carotid intima‐media thickness, troponin I, N‐terminal pro‐brain natriuretic peptide (NT‐proBNP), and insulin resistance as measured by homeostatic model assessment (HOMA index) in a cohort of Saudi patients who are undergoing hemodialysis (HD) vs. continuous ambulatory peritoneal dialysis for end‐stage renal disease. Plasma MPO was significantly higher in patients on continuous ambulatory peritoneal dialysis (CAPD) than in those on HD and in normal subjects (P<0.001). Conversely, NT‐proBNP plasma levels were significantly higher in patients on HD (both predialysis and postdialysis) than in those on CAPD (P<0.01) and than normal subjects. Similarly, plasma troponin‐I levels were significantly higher in patients on HD compared with those of CAPD and than normal subjects (P<0.001). Plasma troponin‐I and NT‐proBNP levels were positively correlated in the 3 groups namely those on CAPD, Pre‐HD, and post‐HD (r: 0.464 and P=0.047; r: 0.330 and P=0.013; and r: 0.452 and P=0.024), respectively. There was no correlation between the MPO level and carotid intima‐media thickness (P>0.05). However, plasma MPO level correlated positively with the white blood cell count in patients on CAPD and in those on HD (P<0.05). Our findings suggest an increased oxidative stress in CAPD patients compared with HD patients, while the reported difference in plasma NT‐proBNP and troponin‐I may be related to the rapid decline of residual renal function in HD and type of membrane used in the HD dialysis procedure itself.     

Psychosocial aspects of children and families treated with hemodialysis

Introduction: The aim of this study was to analyze the selected psychosocial aspects of chronic kidney disease in children treated with hemodialysis (HD). Methods: The study included 25 children treated with HD aged 2 to 18 years and their parents. Data concerning the illness and socio‐demographic parameters was collected. We used the Paediatric Quality of Life Inventory (PedsQL) for patients and for their parents the PedsQL‐proxy version, General Health Questionnaire (GHQ‐12), Berlin Social Support Scales (BSSS), and the Caregivers Burden Scale (CBS) to evaluate health‐related quality of life (QoL) of HD children and their primary caregivers. Findings: In the PedsQL test, the QoL of HD children was lower than in healthy children. Children treated with HD assessed their QoL on the PedsQL questionnaire higher than the primary caregivers, on all subscales as well as an overall health‐related QoL. Scoring below 2 on the GHQ‐12 test was reported in 56% of mothers, which may indicate that psychological symptoms have intensified. There was no correlation between BSSS, CBS, and GHQ‐12. Discussion: The assessment of QoL in pediatric patients would allow for the earliest possible identification of their nonsomatic problems and irregularities. This could, consequently, contribute to improving QoL in both children with chronic kidney disease and their families.     

Qualities of fatigue in patients on chronic hemodialysis

We aimed to assess the relationship among fatigue qualities (FQ) and the association of FQ with various characteristics of chronic hemodialysis (HD) patients. In 68 HD patients, we assessed the Charlson Comorbidity Index (CCI), the Geriatric Depression Scale score (GDS), the Mini Mental Status Examination (MMSE), and measured the laboratory parameters. In addition, patients answered to six questions about FQ (Tiredness: Do you feel tired much of the time? Emotional: Do you feel that life is empty? Cognitive: Do you have trouble concentrating? Sleepiness: Have you had difficulty sleeping in the past month? Weakness: Have you had muscle weakness in the past month? Lack of energy: Do you feel full of energy?). At least one FQ was reported by 62 patients. Muscle weakness (61.7%) was the most frequent and cognitive fatigue (22%) the least. Physical FQ were all more common than the mental ones. Correlation between the two mental FQ (emotional and cognitive) was 0.381 (p = 0.002). Six patients reported none of the FQ, 20 one FQ, 13 two FQ, and 29 three or more FQ. CCI and GDS were associated with all FQ and MMSE with all FQ but sleepiness. Patients reporting ≥3 FQ were older, had more comorbidities, more symptoms of depression, and a lower MMSE score. At multivariate linear regression analysis, the GDS was the only significant predictor of the number of FQ. HD patients report a variety of qualities of fatigue and the number of FQ is independently associated with symptoms of depression.     

Evaluation of the oral health status in Chinese hemodialysis patients

Chronic kidney disease has become a worldwide public health problem, and it negatively affects oral health. However, the data of the hemodialysis (HD) patients in Chinese population is unknown. This study was aimed to evaluate the dental health status and oral hygiene behavior of the HD patients in China. Patients undergoing HD therapy at two hospitals were asked to finish a questionnaire and receive dental examination (DMF‐T). A total of 306 patients, aged 24–88 (58.09 ± 14.06), took part in this study. Although majority of the patients (77.78%) brushed their teeth at least twice a day, few (less than 5%) had ever used dental floss or mouthwash. More than half of the patients have not visited a dentist since the commencement of HD therapy. The dental examination showed that DMF‐T was 9.63 ± 7.54, and the number of filled teeth (F‐T) was only 0.70 ± 1.48. Moreover, the average caries restoration ratio and replacement index were 17.57% and 32.59%, respectively. HD therapy seems to prevent patients from visiting a dentist, and there is a great need for dental treatment for Chinese HD patients.     

Intima-media thickness of carotid arteries and erectile dysfunction in hemodialysis patients

The prevalence of erectile dysfunction (ED) in hemodialysis (HD) is extremely high. The objective of this study was to evaluate the association between the intima-media thickness of carotid arteries and ED in HD patients. The survey was organized as a cross-sectional study in men aged up to 65 years, in the HD. All respondents voluntarily completed the questionnaire of the International Index of Erectile Function-5, adjusted for the Serbian language, verified routine laboratory analysis, calculated body mass index, demographic structure, duration of dialysis, the presence of hepatotropic viruses and erythropoietin therapy, smoking and drinking alcohol, determined the quality of HD, verified significantly comorbidities and measured the intima-media thickness of carotid artery using the Doppler method. The prevalence of ED in our study was 82.2%. Erectile dysfunction significantly more prevalent in older (P = 0.001) and obese patients (P = 0.047). It is significantly represented in patients with cardiovascular disease (P = 0.006), in those who consume alcohol (P = 0.04) and patients with higher values of intima-media thickness of carotid arteries (P = 0.007). Spearman's coefficient of linear correlation (ρ=-0.34, P=0.006) and linear regression (b=-2.02, P<0.001) indicated a negative association between intima-media thickness and the International Index of Erectile Function score. The prevalence of ED in our patients was 82.2%, more common in older and obese patients, a significant determinant of alcohol consumption and cardiovascular disease. Increased thickness of the intima media of the carotid arteries was associated with a higher incidence of ED.     

高职生就业能力与心理健康:积极应对和自我效能感的调节作用

目的探讨高职生就业能力对心理健康的影响,以及积极应对和自我效能感的调节作用。方法采用问卷调查法,对某职业技术学院的246名高职学生进行了测试。结果①高职生就业能力对其心理健康具有正向影响。②高职生的自我效能感和积极应对调节就业能力与心理健康之间的关系。结论当高职生的积极应对和自我效能感高时,就业能力对他们/她们心理健康的影响更大更积极。因此,提升高职生的就业能力,并重视其积极应对方式和自我效能感的培养,有利于高职生的心理健康状况。     

The level of C‐reactive protein in chronic hemodialysis patients: A comparative study between patients with noninfected catheters and arteriovenous fistula in two large Gulf hemodialysis centers

Hemodialysis (HD) patients have greater morbidity and mortality when they have a central venous catheter (CVC) rather than an arteriovenous fistula (AVF) access. Inflammation associated with dialysis catheter use and resultant higher C‐reactive protein (CRP) levels could have an independent adverse effect on patient outcomes. In this prospective study, we investigated whether HD catheters induce inflammation independent of infection. We compared the mean levels of the inflammatory marker (CRP) in 67 patients on maintenance HD using noninfected catheters with 86 HD patients using AVFs at Prince Salman Center for Kidney Diseases, Saudi Arabia (KSA), and Jahra Hospital, Kuwait, who met our inclusion criteria. C‐reactive protein levels were measured every 2 months over a period of 6 months using immunoturbidimetric assay. One hundred fifty‐three patients on maintenance HD for more than 6 months were included in the study, with mean age of 52.19 ± 16.06 years; 66% were males and 34% were females. Serial levels of mean CRP were statistically and significantly higher in group with noninfected catheters (1.33, 1.24, and 1.10 mg/dL) compared to those with AVFs (0.65, 0.59, and 0.68 mg/dL) with P value of 0.000. In our study, we found no relation between CRP level and age, sex, hemoglobin, albumin, calcium, phosphorus, and iPTH level in both groups. Hemodialysis patients with a catheter have a heightened state of inflammation independent of infection, and thus our study supports the avoidance of catheters and a timely conversion to AVFs with catheter removal.     

Hemodialysis in the Elderly

Background:  Health-related quality of life (HRQOL) is an important outcome of medical treatment effectiveness.
Objectives:  Thirty-six item short-Form (SF-36) first has been used in hemodialysis (HD) patients in Taiwan.
Method:  HRQOL was measured by using SF-36 in 497 HD patients in 5 hospitals.
Results:  Male sex, age less than 50 years, higher education level (EL), marriage, employed status (EPS), less comorbid medical condition (CMC), and non-diabetic patients were all predicted a better physical component scale (PCS). Age less than 50 years, BMI greater than 18.5, HEL, EPS, and NDP were all predicted a higher mental component scale (MCS). Scales contributing to a summary measure of physical health, the PCS score, was significantly lower in women (35 ± 12.3) than in men (37.9 ± 12.3). There is no difference in MCS score between women and men. In multivariate analysis, age, CMC, diabetes, serum creatinine (SCr), and erythropoietin responsiveness were significant independent predictors of PCS. Diabetes, EL, SCr, and erythropoietic responsiveness were significant independent predictors of MCS. All of the individual scales, PCS and MCS scores were lower in the Taiwan HD patients than values for the US general population. Each of the individual scales and MCS scores were substantially lower in Taiwan HD group than in the US HD cohort. But the bodily pain of PCS was significantly higher in Taiwan HD group in spite of mean PCS scores for Taiwan HD group and US HD study participants were nearly equal at 36.3 and 36.1, respectively.
Conclusion:  Physical and mental aspects of quality of life are substantially reduced among Taiwan HD patients, but higher bodily pain tolerance. A number of demographic and clinical characteristics significantly impact on HRQOL in Taiwan HD patients. To our knowledge, this is the first time we demonstrate the HRQOL by using SF-36 in Chinese HD patients.     

Effects of modality change on health-related quality of life

Patients with end‐stage renal disease (ESRD) requiring renal replacement have impaired health‐related quality of life (HRQoL), and there is general consensus that HRQoL improves with successful transplant and evidence of improvement with frequent hemodialysis. This study reports changes in HRQoL associated with changes in treatment modality to daily hemodialysis (DHD) and transplant among patients requiring renal replacement. This cohort study had assessments at baseline and 6‐month following modality change. Subjects were nondiabetic individuals receiving conventional hemodialysis who (a) remained on conventional hemodialysis (n = 13), (b) changed to daily hemodialysis (DHD) (n = 10), or (c) received a living donor transplant (n = 20). Thirty‐four healthy controls were assessed once for comparison. HRQoL was measured using the Kidney Disease Quality of Life Instrument. The Physical Functioning and Physical Composite Scale scores were primary outcomes. Transplantation resulted in significant improvements in six of eight generic scales and the physical composite scale (PCS). Those changing to DHD had significant improvements in Physical Function and PCS scales. Those remaining on dialysis remained lower than controls on all scales except for Vitality; the transplant group remained lower than controls only on the Vitality and General Health scales. Transplant resulted in significant improvements in four of the seven disease‐specific scales (symptoms, effects, and burden of kidney disease, work). DHD resulted in improvements in the effects of kidney disease. Modality change to transplant results in significant improvement in HRQoL, achieving levels similar to controls. Change to daily hemodialysis improves only select HRQoL domains and remains low in disease‐specific domains.     

Prevention of hemodialysis-related muscle cramps by intradialytic use of sequential compression devices: A report of four cases

Background: Hemodialysis (HD)‐related lower extremity (LE) muscle cramps are a common cause of morbidity in end‐stage renal disease patients on maintenance HD. Numerous pharmacologic and physical measures have been tried with variable success rates. Methods: Sequential compression devices (SCD) improve venous return (VR) and are commonly used to prevent LE deep venous thrombosis in hospitals. We hypothesized that LE cramps are triggered by stagnant venous flow during HD and are preventable by improving VR. We prospectively studied four adult patients (mean age 61 ± 14 years) on thrice‐weekly HD who experienced two or more episodes of LE cramping weekly in the month before the study. SCD were applied before each HD on both legs and compressions were intermittently applied at 40 mmHg during treatment. Results: All four patients reported complete resolution of cramping during the study period that lasted 1 month or 12 consecutive dialysis treatments. Conclusion: Application of SCD to LE may prevent the generation of LE HD‐related cramping in a select group of patients. Larger, controlled studies are needed to establish the utility of this noninvasive alternative for the prevention of LE HD‐related cramps.     

When pure is not so pure: Chloramine‐related hemolytic anemia in home hemodialysis patients

Worldwide, chloramines are used as the preferred disinfectant for city water supplies. Although they have distinct advantages compared with chlorine and are deemed harmless to the general population, hemodialysis (HD) patients are at risk from chloramine‐induced hemolytic anemia. In recent years, this has been highlighted in regional dialysis units but not as frequently in the home HD group. We report on 2 home HD patients who succumbed to severe oxidative hemolysis due to high mains water chloramine concentrations. Both patients were extensively investigated for other cause of anemia before a definitive diagnosis was reached. Delays in diagnosing this uncommon condition can be costly in terms of significant morbidity and excessive usage of recombinant erythropoietin and blood transfusion. Prevention primarily involves enforcing strict water quality control and establishing regular communication with water supply boards and home HD patients. Double (inline) carbon filters should be installed in patient's homes as an effective means for removing high incoming chloramine concentrations.     

Pruritus in hemodialysis patients: Results from the Japanese Dialysis Outcomes and Practice Patterns Study (JDOPPS)

Pruritus affects many patients undergoing hemodialysis (HD). In this study, pruritus and its relationship to morbidity, quality of life (QoL), sleep quality, and patient laboratory measures were analyzed in a large sample of Japanese patients undergoing HD. Severity of patient‐reported pruritus symptoms experienced during a 4‐week period was collected from 6480 Japanese patients undergoing HD in three phases of the Dialysis Outcomes and Practice Patterns Study (DOPPS; 1996–2008; 60–65 study facilities/phase). Adjusted linear and logistic regressions were used to identify associations of pruritus with treatment parameters and QoL outcomes. Adjusted Cox regressions examined the influence of pruritus severity on mortality. Moderate to extreme pruritus was experienced by 44% of prevalent patients undergoing HD in the Japanese Dialysis Outcomes and Practice Patterns Study. Many patient characteristics were significantly associated with pruritus, but this did not explain the large differences in pruritus among facilities (20–70%). Pruritus was slightly less common in patients starting HD than in patients on dialysis >1 year. Patients with moderate to extreme pruritus were more likely to feel drained (adjusted odds ratio = 2.2–5.8, P < 0.0001), have poor sleep quality (adjusted odds ratio = 1.9–3.7, P < 0.0001), and have QoL mental and physical composite scores 2.3–6.7 points lower (P < 0.0001) than patients with no/mild pruritus. Pruritus in patients undergoing HD was associated with a 23% higher mortality risk (P = 0.09). The many poor outcomes associated with pruritus underscore the need for better therapeutic agents to provide relief for the 40–50% of prevalent patients undergoing HD substantially affected by pruritus. Pruritus in new patients with end‐stage renal disease likely results from uremia or pre‐existing conditions (not HD per se), indicating the need to understand development of pruritus before end‐stage renal disease.