nursing research studies on dialysis

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• Review Article
• Published: 30 July 2020

The current and future landscape of dialysis

• Jonathan Himmelfarb   ORCID: orcid.org/0000-0002-3319-1224 1 , 2 ,
• Raymond Vanholder   ORCID: orcid.org/0000-0003-2633-1636 3 ,
• Rajnish Mehrotra   ORCID: orcid.org/0000-0003-2833-067X 1 , 2 &
• Marcello Tonelli   ORCID: orcid.org/0000-0002-0846-3187 4  

Nature Reviews Nephrology volume  16 ,  pages 573–585 ( 2020 ) Cite this article

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• Haemodialysis
• Health care economics
• Health services
• Medical ethics

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis — particularly haemodialysis and most notably in high-income countries (HICs) — the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization.

The global dialysis population is growing rapidly, especially in low-income and middle-income countries; however, worldwide, a substantial number of people lack access to kidney replacement therapy, and millions of people die of kidney failure each year, often without supportive care.

The costs of dialysis care are high and will likely continue to rise as a result of increased life expectancy and improved therapies for causes of kidney failure such as diabetes mellitus and cardiovascular disease.

Patients on dialysis continue to bear a high burden of disease, shortened life expectancy and report a high symptom burden and a low health-related quality of life.

Patient-focused research has identified fatigue, insomnia, cramps, depression, anxiety and frustration as key symptoms contributing to unsatisfactory outcomes for patients on dialysis.

Initiatives to transform dialysis outcomes for patients require both top-down efforts (that is, efforts that promote incentives based on systems level policy, regulations, macroeconomic and organizational changes) and bottom-up efforts (that is, patient-led and patient-centred advocacy efforts as well as efforts led by individual teams of innovators).

Patients, payors, regulators and health-care systems increasingly demand improved value in dialysis care, which can only come about through true patient-centred innovation that supports high-quality, high-value care.

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Kidney disease trials for the 21st century: innovations in design and conduct

Introduction.

Haemodialysis as a treatment for irreversible kidney failure arose from the pioneering efforts of Willem Kolff and Belding Scribner, who together received the 2002 Albert Lasker Clinical Medical Research Award for this accomplishment. Kolff treated his first patient with an artificial kidney in 1943 — a young woman who was dialysed 12 times successfully but ultimately died because of vascular access failure. By 1945, Kolff had dialysed 15 more patients who did not survive, when Sofia Schafstadt — a 67-year-old woman who had developed acute kidney injury — recovered, becoming the first long-term survivor after receipt of dialysis. In 1960, Belding Scribner, Wayne Quinton and colleagues at the University of Washington, WA, USA, designed shunted cannulas, which prevented the destruction of blood vessels and enabled repeated haemodialysis sessions. The first patient who received long-term treatment (named Clyde Shields) lived a further 11 years on haemodialysis. In their writings, both Kolff and Scribner eloquently described being motivated by their perception of helplessness as physicians who had little to offer for the care of young patients who were dying of uraemia and stated that the goal of dialysis was to achieve full rehabilitation to an enjoyable life 1 .

The potential to scale the use of dialysis to treat large numbers of patients with kidney failure created great excitement. At the 1960 meeting of the American Society for Artificial Internal Organs (ASAIO), Scribner introduced Clyde Shields to physicians interested in dialysis, and Quinton demonstrated fabrication of the shunt. The following decade saw rapid gains in our understanding of kidney failure, including the discovery of uraemia-associated atherogenesis and metabolic bone disease, and in virtually every aspect of haemodialysis, including improvements in dialyser technology, dialysate composition, materials for haemocompatibility and water purification systems. The Scribner–Quinton shunt rapidly became an historical artefact once Brescia and colleagues developed the endogenous arteriovenous fistula in 1966 (ref. 2 ), and prosthetic subcutaneous interpositional ‘bridge’ grafts were developed shortly thereafter. Concomitant with these pioneering efforts, in 1959, peritoneal dialysis (PD) was first used successfully to sustain life for 6 months. Within 2 years a long-term PD programme was established in Seattle, WA, USA, and within 3 years the first automated PD cycler was developed 3 .

In 1964, Scribner’s presidential address to the ASAIO described emerging ethical issues related to dialysis, including considerations for patient selection, patient self-termination of treatment as a form of suicide, approaches to ensure death with dignity and selection criteria for transplantation 4 . Indeed, the process of selecting who would receive dialysis contributed to the emergence of the field of bioethics. The early success of dialysis paradoxically created social tensions, as access to this life-sustaining therapy was rationed by its availability and the ‘suitability’ of patients. In the early 1970s, haemodialysis remained a highly specialized therapy, available to ~10,000 individuals, almost exclusively in North America and Europe, with a high frequency of patients on home haemodialysis. In a portentous moment, Shep Glazer, an unemployed salesman, was dialysed in a live demonstration in front of the US Congress House Ways and Means Committee. Soon thereafter, in October 1972, an amendment to the Social Security Act creating Medicare entitlement for end-stage renal disease (now known as kidney failure), for both dialysis and kidney transplantation, was passed by Congress and signed into law by President Nixon.

The resulting expansion of dialysis, previously described as “from miracle to mainstream” 5 , set in motion dramatic changes 6 , including the development of a for-profit outpatient dialysis provider industry; relaxation of stringent patient selection for dialysis eligibility in most HICs; a move away from home towards in-centre dialysis; efforts on the part of single payors such as Medicare in the USA to restrain per-patient costs through the introduction of bundled payments and the setting of composite rates; the development of quality indicators — such as adequate urea clearance per treatment — that were readily achievable but are primarily process rather than outcome measures; consolidation of the dialysis industry, particularly in the USA owing to economies of scale, eventually resulting in a duopoly of dialysis providers; the development of joint ventures and other forms of partnerships between dialysis providers and nephrologists; the globalization of dialysis, which is now available, albeit not necessarily accessible or affordable in many low-income and middle-income countries (LMICs); and finally, a dramatic slowing in the rate of true patient-centred innovation, with incremental gains in dialysis safety and efficiency replacing the pioneering spirit of the early innovators.

The population of patients receiving dialysis continues to grow rapidly, especially in LMICs, as a result of an increase in the availability of dialysis, population ageing, increased prevalence of hypertension and diabetes mellitus, and toxic environmental exposures. However, despite the global expansion of dialysis, notable regional differences exist in the prevalence of different dialysis modalities and in its accessibility. Worldwide, a substantial number of people do not have access to kidney replacement therapy (KRT), resulting in millions of deaths from kidney failure each year. Among populations with access to dialysis, mortality remains high and outcomes suboptimal, with high rates of comorbidities and poor health-related quality of life. These shortcomings highlight the urgent need for innovations in the dialysis space to increase accessibility and improve outcomes, with a focus on those that are a priority to patients. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and provides examples of initiatives that are aimed at stimulating innovations in dialysis and transform the field to one that supports high-quality, high-value care.

Epidemiology of dialysis

Kidney failure is defined by a glomerular filtration rate <15 ml/min/1.73 m 2 (ref. 7 ) and may be treated using KRT (which refers to either dialysis or transplantation) or with supportive care 8 . The global prevalence of kidney failure is uncertain, but was estimated to be 0.07%, or approximately 5.3 million people in 2017 (ref. 9 ), with other estimates ranging as high as 9.7 million. Worldwide, millions of people die of kidney failure each year owing to a lack of access to KRT 10 , often without supportive care. Haemodialysis is costly, and current recommendations therefore suggest that haemodialysis should be the lowest priority for LMICs seeking to establish kidney care programmes. Rather, these programmes should prioritize other approaches, including treatments to prevent or delay kidney failure, conservative care, living donor kidney transplantation and PD 11 . Nonetheless, haemodialysis is the most commonly offered form of KRT in LMICs, as well as in high-income countries (HICs) 12 , and continued increases in the uptake of haemodialysis are expected worldwide in the coming decades. Here, we review the basic epidemiology of kidney failure treated with long-term dialysis and discuss some of the key epidemiological challenges of the future (Fig.  1a ).

Growth is continuously outpacing the capacity of kidney replacement therapy (KRT), defined as maintenance dialysis or kidney transplant, especially in low-income and middle-income countries. a | Global prevalence of chronic dialysis. b | Estimated worldwide need and projected capacity for KRT by 2030. pmp, per million population. Adapted with permission from the ISN Global Kidney Health Atlas 2019.

Prevalence of dialysis use

Prevalence of haemodialysis.

Worldwide, approximately 89% of patients on dialysis receive haemodialysis; the majority (>90%) of patients on haemodialysis live in HICs or the so-called upper middle-income countries such as Brazil and South Africa 12 , 13 . The apparent prevalence of long-term dialysis varies widely by region but correlates strongly with national income 14 . This variation in prevalence in part reflects true differences in dialysis use 12 , 15 but also reflects the fact that wealthier countries are more likely than lower income countries to have comprehensive dialysis registries. Of note, the prevalence of haemodialysis is increasing more rapidly in Latin America (at a rate of ~4% per year) than in Europe or the USA (both ~2% per year), although considerable variation between territories exists in all three of these regions, which again correlates primarily (but not exclusively) with wealth 16 , 17 . The prevalence of haemodialysis varies widely across South Asia, with relatively high prevalence (and rapid growth) in India and lower prevalence in Afghanistan and Bangladesh 18 . Limited data are available on the prevalence of dialysis therapies in sub-Saharan Africa 19 . A 2017 report suggests that haemodialysis services were available in at least 34 African countries as of 2017, although haemodialysis was not affordable or accessible to the large majority of resident candidates 13 .

Prevalence of peritoneal dialysis

Worldwide, PD is less widely available than haemodialysis. In a 2017 survey of 125 countries, PD was reportedly available in 75% of countries whereas haemodialysis was available in 96% 20 . In 2018, an estimated 11% of patients receiving long-term dialysis worldwide were treated with PD; a little over half of these patients were living in China, Mexico, the USA and Thailand 21 .

Large variation exists between territories in the relative use of PD for treating kidney failure; in Hong Kong for example, >80% of patients on dialysis receive PD, whereas in Japan this proportion is <5% 22 . This variation is, in part, determined by governmental policies and the density of haemodialysis facilities 23 . In some countries such as the USA, rates of PD utilization also vary by ethnicity with African Americans and Hispanics being much less likely than white Americans to receive PD 24 . Disparate secular trends in PD use are also evident, with rapid growth in the use of PD in some regions such as the USA, China and Thailand and declining or unchanging levels of PD use in other regions, for example, within Western Europe 22 . As for haemodialysis, access to PD is poor in many LMICs for a variety of reasons, as comprehensively discussed elsewhere 25 .

Incidence of dialysis use

Following a rapid increase in dialysis use over a period of approximately two decades, the incidence of dialysis initiation in most HICs reached a peak in the early 2000s and has remained stable or slightly decreased since then 22 , 26 , 27 . Extrapolation of prevalence data from LMICs suggests that the incidence of dialysis initiation seems to be steadily increasing in LMICs 10 , 28 , 29 , 30 , with further increases expected over the coming decades. However, incidence data in LMICs are less robust than prevalence data, although neither reflect the true demand for KRT given the lack of reporting.

Of note, the incidence of dialysis initiation in HICs is consistently 1.2-fold to 1.4-fold higher for men than for women, despite an apparently higher risk of chronic kidney disease (CKD) in women 31 . Whether this finding reflects physician or health system bias, different preferences with regard to KRT, disparities in the competing risk of death, variation in rates of kidney function loss in women versus men, or other reasons is unknown and requires further study. Few data describe the incidence of haemodialysis by sex in LMICs.

Dialysis outcomes

Mortality is very high among patients on dialysis, especially in the first 3 months following initiation of haemodialysis treatment. Approximately one-quarter of patients on haemodialysis die within a year of initiating therapy in HICs, and this proportion is even higher in LMICs 32 , 33 , 34 . Over the past two decades, reductions in the relative and absolute risk of mortality have seemingly been achieved for patients on haemodialysis. Data suggest that relative gains in survival may be greater for younger than for older individuals; however, absolute gains seem to be similar across age groups 35 . Although controversial, improvements in mortality risk seem to have been more rapid among patients on dialysis than for the general population 36 , suggesting that better care of patients receiving dialysis treatments rather than overall health gains might be at least partially responsible for these secular trends. The factors responsible for these apparent trends have not been confirmed, but could include better management of comorbidities, improvements in the prevention or treatment of dialysis-related complications such as infection, and/or better care prior to the initiation of dialysis (which may translate into better health following dialysis initiation). Historically, although short-term mortality was lower for patients treated with PD than for those treated with haemodialysis, the long-term mortality risk was higher with PD 37 , 38 . In the past two decades, the reduction in mortality risk has been greater for patients treated with PD than with haemodialysis, such that in most regions the long-term survival of patients treated with PD and haemodialysis are now similar 39 , 40 , 41 .

Despite these improvements, mortality remains unacceptably high among patients on dialysis and is driven by cardiovascular events and infection. For example, a 2019 study showed that cardiovascular mortality among young adults aged 22–29 years with incident kidney failure was 143–500-fold higher than that of otherwise comparable individuals without kidney failure, owing to a very high burden of cardiovascular risk factors 42 . The risk of infection is also markedly greater among patients on dialysis than in the general population, in part driven by access-related infections in patients on haemodialysis with central venous catheters and peritonitis-related infections in patients on PD 43 , 44 , 45 , 46 , 47 . Hence, strategies to reduce the risk of infection associated with dialysis access should continue to be a high clinical priority.

The risk of mortality among patients on dialysis seems to be influenced by race. In the USA, adjusted mortality is lower for African American patients than for white patients on dialysis, although there is a significant interaction with age such that this observation held only among older adults, and the converse is actually true among younger African American patients aged 18 to 30 years 48 . A similar survival advantage is observed among Black patients compared with white patients or patients of Asian heritage on haemodialysis in the Netherlands 49 . In Canada, dialysis patients of indigenous descent have higher adjusted mortality, and patients of South Asian or East Asian ethnicity have lower adjusted mortality than that of white patients. In addition, between-region comparisons indicate that mortality among incident dialysis patients is substantially lower for Japan than for other HICs. Whether this difference is due to ethnic origin, differences in health system practices, a combination of these factors or other, unrelated factors is unknown 30 . No consistent evidence exists to suggest that mortality among incident adult dialysis patients varies significantly by sex 50 , 51 , 52 .

Other outcomes

Hospitalization, inability to work and loss of independent living are all markedly more common among patients on dialysis than in the general population 53 , 54 , 55 . In contrast to the modest secular improvements in mortality achieved for patients on dialysis, health-related quality of life has remained unchanged for the past two decades and is substantially lower than that of the general population, due in part to high symptom burden 56 , 57 , 58 , 59 . Depression is also frequent among patients on dialysis 60 , and factors such as high pill burden 61 , the need to travel to dialysis sessions and pain associated with vascular access puncture all affect quality of life 62 .

Future epidemiological challenges

The changing epidemiology of kidney failure is likely to present several challenges for the optimal management of these patients. For example, the ageing global population together with continuing increases in the prevalence of key risk factors for the development of kidney disease, such as diabetes mellitus and hypertension, mean that the incidence, prevalence and costs of kidney failure will continue to rise for the foreseeable future. This increased demand for KRT will undoubtedly lead to an increase in the uptake of haemodialysis, which will pose substantial economic challenges for health systems worldwide. Moreover, as growth in demand seems to be outpacing increases in KRT capacity, the number of deaths as a result of kidney failure is expected to rise dramatically (Fig.  1b ).

The same risk factors that drive the development of kidney disease will also increase the prevalence of multimorbidities within the dialysis population. These comorbidities will in turn require effective management in addition to the management of kidney failure per se 63 and will require technical innovations of dialysis procedures, as well as better evidence to guide the management of comorbidities in the dialysis population.

Finally, the particularly rapid increases in the incidence and prevalence of kidney failure among populations in LMICs will place considerable strain on the health systems of these countries. The associated increases in mortality resulting from a lack of access to KRT will create difficult choices for decision makers. Although LMIC should prioritize forms of KRT other than haemodialysis, some haemodialysis capacity will be required 11 , for example, to manage patients with hypercatabolic acute kidney injury or refractory PD-associated peritonitis, which, once available, will inevitably increase the use of this modality.

Health economy-related considerations

The cost of dialysis (especially in-centre or in-hospital dialysis) is high 64 , and the cost per quality-adjusted life-year associated with haemodialysis treatment is often considered to be the threshold value that differentiates whether a particular medical intervention is cost-effective or not 65 . Total dialysis costs across the population will probably continue to rise, owing to increases in life expectancy of the general population and the availability of improved therapeutics for causes of kidney failure such as diabetes mellitus, which have increased the lifespan of these patients and probably will also increase their lifespan on dialysis. KRT absorbs up to 5–7% of total health-care budgets, despite the fact that kidney failure affects only 0.1–0.2% of the general population in most regions 66 . Although societal costs for out-of-centre dialysis (for example, home or self-care haemodialysis, or PD) are in general lower than that of in-centre haemodialysis in many HICs, these options are often underutilized 67 , adding to the rising costs of dialysis.

Reimbursement for haemodialysis correlates with the economic strength of each region 68 , but in part also reflects willingness to pay . In most regions, the correlation curve for PD or reimbursement with respect to gross domestic product projects below that of in-centre haemodialysis, which in part reflects the lower labour costs associated with PD 68 . Unfortunately, little clarity exists with regard to the aggregated cost of single items that are required to produce dialysis equipment for both PD and haemodialysis and the labour costs involved in delivering haemodialysis 69 , which makes it difficult for governments to reimburse the real costs of haemodialysis.

Although increasing reimbursement of home dialysis strategies would seem to be an appropriate strategy to stimulate uptake of these modalities, evidence from regions that offer high reimbursement rates for PD suggests that the success of this strategy is variable 23 , 68 . However, financial incentives may work. In the USA, reimbursement for in-centre and home dialysis (PD or home haemodialysis) has for a long time been identical. The introduction of the expanded prospective payment system in 2011 further enhanced the financial incentives for PD for dialysis providers, which led to a doubling in both the absolute number of patients and the proportion of patients with kidney failure treated with PD 70 , 71 , 72 , 73 .

Although in countries with a low gross domestic product, dialysis consumes less in absolute amounts, it absorbs a higher fraction of the global health budget 68 , likely at the expense of other, potentially more cost-effective interventions, such as prevention or transplantation. Although society carries most of the costs associated with KRT in most HICs, some costs such as co-payment for drugs or consultations are borne by the individual, and these often increase as CKD progresses. In other regions, costs are covered largely or entirely by the patient’s family, leading to premature death when resources are exhausted 74 . In addition, costs are not limited to KRT but also include the costs of medication, hospitalizations and interventions linked to kidney disease or its complications (that is, indirect costs), as well as non-health-care-related costs such as those linked to transportation or loss of productivity.

Dialysis also has an intrinsic economic impact. Patients on dialysis are often unemployed. In the USA, >75% of patients are unemployed at the start of dialysis, compared with <20% in the general population 53 . Unemployment affects purchasing power but also lifestyle, self-image and mental health. Moreover, loss of productivity owing to unemployment and/or the premature death of workers with kidney failure also has economic consequences for society 75 . Therefore, continued efforts to prevent kidney failure and develop KRT strategies that are less time consuming for the patient and allow more flexibility should be an urgent priority. Concomitantly, employers must also provide the resources needed to support employees with kidney failure.

Hence, a pressing need exists to rethink the current economic model of dialysis and the policies that direct the choice of different treatment options. The cost of dialysis (especially that of in-centre haemodialysis) is considerable and will continue to rise as the dialysis population increases. Maintaining the status quo will prevent timely access to optimal treatment for many patients, especially for those living in extreme poverty and with a low level of education and for patients living in LMICs.

Ethical aspects

A 2020 review by a panel of nephrologists and ethicists appointed by three large nephrology societies outlined the main ethical concerns associated with kidney care 76 . With regard to management of kidney failure (Box  1 ), equitable access to appropriate treatment is probably the most important ethical issue and is relevant not only in the context of haemodialysis but also for the other modalities of kidney care (including transplantation, PD and comprehensive conservative care) 76 . Of note, conservative care is not equivalent to the withdrawal of treatment, but rather implies active management excluding KRT.

As mentioned previously, access to such care is limited in many countries 10 , 77 . Inequities in access to dialysis at the individual level are largely dependent on factors such as health literacy, education and socio-economic status, but also on the wealth and organization of the region in which the individual lives. Even when dialysis itself is reimbursed, a lack of individual financial resources can limit access to care. Moreover, elements such as gender, race or ethnicity and citizenship status 78 , 79 can influence an individual’s ability to access dialysis 80 . These factors impose a risk that patients who are most vulnerable are subject to further discrimination. In addition, without necessarily being perceived as such, dialysis delivery may be biased by the financial interests of dialysis providers or nephrologists, for example, by influencing whether a patient receives in-centre versus home dialysis, or resulting in the non-referral of patients on dialysis for transplantation or conservative care 81 , 82 .

A potential reason for the high utilization of in-centre haemodialysis worldwide is a lack of patient awareness regarding the alternatives. When surveyed, a considerable proportion of patients with kidney failure reported that information about options for KRT was inadequate 83 , 84 . Patient education and decision support could be strengthened and its quality benchmarked, with specific attention to low health literacy, which is frequent among patients on dialysis 85 . Inadequate patient education might result from a lack of familiarity with home dialysis (including PD) and candidacy bias among treating physicians and nurses. Appropriate education and training of medical professionals could help to solve this problem. However, the first step to increase uptake of home dialysis modalities is likely policy action undertaken by administrations, but stimulated by advocacy by patients and the nephrology community, as suggested by the higher prevalence of PD at a lower societal cost of regions that already have a PD-first policy in place 68 .

Although the provision of appropriate dialysis at the lowest possible cost to the individual is essential if access is to be improved 86 , approaches that unduly compromise the quality of care should be minimized or avoided. General frameworks to deal with this challenge can be provided by the nephrology community, but trade-offs between cost and quality may be necessary and will require consultation between authorities, medical professionals and patient representatives. Consideration must also be given to whether the societal and individual impact of providing dialysis would be greater than managing other societal health priorities (for example, malaria or tuberculosis) or investing in other sectors to improve health (for example, access to clean drinking water or improving road safety).

The most favourable approach in deciding the most appropriate course of action for an individual is shared decision-making 87 , which provides evidence-based information to patients and families about all available therapeutic options in the context of the local situation. Providing accurate and unbiased information to support such decision-making is especially relevant for conservative care, to avoid the perception that this approach is being recommended to save resources rather than to pursue optimal patient comfort. Properly done, shared decision-making should avoid coercion, manipulation, conflicts of interest and the provision of ‘futile dialysis’ to a patient for whom the harm outweighs the benefits, life expectancy is low or the financial burden is high 88 . However, the views of care providers do not always necessarily align with those of patients and their families, especially in multicultural environments 89 . Medical professionals are often not well prepared for shared decision-making, and thus proper training is essential 90 . Policy action is also required to create the proper ethical consensus and evidence-based frameworks at institutional and government levels 91 to guide decision-making in the context of dialysis care that can be adapted to meet local needs.

Box 1 Main ethical issues in dialysis

Equity in access to long-term dialysis

Inequities in the ability to access kidney replacement therapy exist worldwide; however, if dialysis is available, the ability to transition between different dialysis modalities should be facilitated as much as possible. Specific attention should be paid to the factors that most prominently influence access to dialysis, such as gender, ethnicity, citizenship status and socio-economic status

Impact of financial interests on dialysis delivery

Financial interests of dialysis providers or nephrologists should in no way influence the choice of dialysis modality and/or result in the non-referral of patients for transplantation or conservative care

Cost considerations

Local adaptations are needed to ensure that the costs of dialysis provision are as low as possible without compromising quality of care

The high cost of dialysis means that consideration must be given to whether the benefits obtained by dialysis outweigh those obtained by addressing other health-care priorities, such as malaria or tuberculosis

Shared decision-making

Shared decision-making, involving the patient and their family, is recommended as an approach to allow an informed choice of the most appropriate course to follow

Approaches to shared decision-making must be evidence based and adapted to local circumstances

Futile dialysis should be avoided

Proper training is required to prepare physicians for shared decision-making

Clinical outcomes to measure progress

Over the past six decades, the availability of long-term dialysis has prolonged the lives of millions of people worldwide, often by serving as a bridge to kidney transplantation. Yet, patients on dialysis continue to bear a high burden of disease, both from multimorbidity and owing to the fact that current dialysis modalities only partially replace the function of the native kidney, resulting in continued uraemia and its consequences. Thus, although dialysis prevents death from kidney failure, life expectancy is often poor, hospitalizations (particularly for cardiovascular events and infection) are frequent, symptom burden is high and health-related quality of life is low 22 , 92 , 93 .

Given the multitude of health challenges faced by patients on dialysis, it is necessary to develop a priority list of issues. For much of the past three decades, most of this prioritization was performed by nephrology researchers with the most effort to date focusing on approaches to reducing all-cause mortality and the risk of fatal and non-fatal cardiovascular events. However, despite the many interventions that have been tested, including increasing the dose of dialysis (in the HEMO and ADEMEX trials 94 , 95 ), increasing dialyser flux (in the HEMO trial and MPO trial 94 , 96 ), increasing haemodialysis frequency (for example, the FHN Daily and FHN Nocturnal trials 97 , 98 ), use of haemodiafiltration (the CONTRAST 99 , ESHOL 100 and TURKISH-OL-HDF trials 101 ), increasing the haemoglobin target (for example, the Normal Haematocrit Trial 102 ), use of non-calcium-based phosphate binders (for example, the DCOR trial 103 ), or lowering of the serum cholesterol level (for example, the 4D, AURORA and SHARP trials 104 , 105 , 106 ), none of these or other interventions has clearly reduced all-cause or cardiovascular mortality for patients on dialysis. These disappointments notwithstanding, it is important that the nephrology community perseveres in finding ways to improve patient outcomes.

In the past 5 years, nephrology researchers have increasingly engaged with patients to understand their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that although longevity is valued, many patients would prefer to reduce symptom burden and achieve maximal functional and social rehabilitation. This insight highlights the high symptom burden experienced by patients receiving long-term dialysis 92 , 93 , 96 , 107 . These symptoms arise as a consequence of the uraemic syndrome. Some of these symptoms, such as anorexia, nausea, vomiting, shortness of breath and confusion or encephalopathy, improve with dialysis initiation 108 , 109 , 110 , but many other symptoms, such as depression, anxiety and insomnia do not. Moreover, other symptoms, such as post-dialysis fatigue, appear after initiation of haemodialysis.

Of note, many symptoms of uraemic syndrome might relate to the persistence of protein-bound uraemic toxins and small peptides (so-called middle molecules) that are not effectively removed by the current dialysis modalities. The development of methods to improve the removal of those compounds is one promising approach to improving outcomes and quality of life for patients on dialysis, as discussed by other articles in this issue.

Patients on dialysis report an average of 9–12 symptoms at any given time 92 , 93 , 107 . To determine which of these should be prioritized for intervention, the Kidney Health Initiative used a two-step patient-focused process involving focus groups and an online survey to identify six symptoms that should be prioritized by the research community for intervention. These include three physical symptoms (fatigue, insomnia and cramps) and three mood symptoms (depression, anxiety and frustration) 111 . Parallel to these efforts, the Standardizing Outcomes in Nephrology Group (SONG) workgroup for haemodialysis ( SONG-HD ) has identified several tiers of outcomes that are important to patients, caregivers and health-care providers. Fatigue was identified as one of the four core outcomes, whereas depression, pain and feeling washed out after haemodialysis were identified as middle-tier outcomes 112 , 113 , 114 . Along these same lines, the SONG workgroup for PD ( SONG-PD ) identified the symptoms of fatigue, PD pain and sleep as important middle-tier outcomes 115 , 116 . Despite the importance of these symptoms to patients on dialysis, only a few studies have assessed the efficacy of behavioural and pharmacological treatments on depression 117 , 118 , 119 , 120 , 121 . Even more sobering is the observation that very few, if any, published studies have rigorously tested interventions for fatigue or any of the other symptoms. The nephrology community must now develop standardized and psychometrically robust measures that accurately capture symptoms and outcomes that are important to patients and ensure that these are captured in future clinical trials 122 , 123 .

Approaches to maximizing functional and social rehabilitation are also important to patients with kidney failure. In addition to the above-mentioned symptoms, SONG-HD identified ability to travel, ability to work, dialysis-free time, impact of dialysis on family and/or friends and mobility as important middle-tier outcomes 112 , 113 , 114 . SONG-PD identified life participation as one of five core outcomes, and impact on family and/or friends and mobility as other outcomes that are important to patients 115 , 116 . Given the importance of these outcomes to stakeholders, including patients, it is imperative that nephrology researchers develop tools to enable valid and consistent measurement of these outcomes and identify interventions that favourably modify these outcomes.

Fostering innovation

As described above, the status quo of dialysis care is suboptimal. Residual symptom burden, morbidity and mortality, and economic cost are all unacceptable, which begs the question of what steps are needed to change the established patterns of care. Patients are currently unable to live full and productive lives owing to the emotional and physical toll of dialysis, its intermittent treatment schedule, the dietary and fluid limitations, and their highly restricted mobility during treatment. Current technology requires most patients to travel to a dialysis centre, and current modalities are non-physiological, resulting in ‘washout’, which is defined as extensive fatigue, nausea and other adverse effects, caused by the build-up of uraemic toxins between treatments and the rapid removal of these solutes and fluids over 4-h sessions in the context of haemodialysis. LMICs face additional difficulties in the provision of dialysis owing to infrastructural requirements, the high cost of this treatment, the need for a constant power supply and the requirement for high volumes of purified water. For LMICs, innovations that focus on home-based, low-cost therapies that promote rehabilitation would be especially beneficial.

We contend that initiatives to transform dialysis outcomes for patients require both top-down efforts (for example, those that involve systems changes at the policy, regulatory, macroeconomic and organizational levels) and bottom-up efforts (for example, patient-led and patient-centred advocacy and individual teams of innovators). Top-down efforts are required to support, facilitate and de-risk the work of innovators. Conversely, patient-led advocacy is essential for influencing governmental and organizational policy change. Here, by considering how selected programmes are attempting to transform dialysis outcomes through innovation in support of high-value, high-quality care, we describe how top-down and bottom-up efforts can work synergistically to change the existing ecosystem of dialysis care (Fig.  2 ). The efforts described below are not an exhaustive list; rather, this discussion is intended to provide a representative overview of how the dialysis landscape is changing. Additional articles in this issue describe in more detail some of the bottom-up efforts of innovators to create wearable 124 , portable 125 , more environmentally friendly 126 and more physiological dialysis systems 127 , 128 , priorities from the patients’ perspective 129 , and the role of regulators in supporting innovation in the dialysis space 130 .

Initiatives to transform dialysis outcomes for patients require both top-down efforts (for example, those that involve systems-level changes at the policy, regulatory, macroeconomic and organizational level) and bottom-up efforts (for example, patient-led and patient-centred advocacy efforts and efforts from individual teams of innovators). Both of these efforts need to be guided by priorities identified by patients. Such an approach, focused on patient-centred innovation, has the potential to result in meaningful innovations that support high-quality, high-value care. NGOs, non-governmental organizations.

The Kidney Health Initiative

In 2012, the American Society of Nephrology (ASN) and the FDA established the KHI as an umbrella organization through which the kidney community can work collaboratively to remove barriers to the development of innovative drugs, devices, biologics and food products, in order to improve outcomes for people living with kidney diseases. To advance its mission, KHI has initiated a number of projects composed of multidisciplinary workgroups. A major accomplishment for the KHI was the establishment of a precompetitive environment to promote innovation while ensuring patient safety.

The KHI is the largest consortium in the kidney community, with over 100 member organizations including patient groups, health professional organizations, dialysis organizations, pharmaceutical and device companies, and government agencies. During the first 7 years of its existence, the KHI has launched and in many cases completed projects that have facilitated the development of new therapeutic options for dialysis patients (Box  2 ), as well as published position papers on topics relevant to innovation in haemodialysis care, including innovations in fluid management 131 and symptom management 132 in patients on haemodialysis, recommendations for clinical trial end points for vascular access 133 , perspectives on pragmatic trials in the haemodialysis population 134 and regulatory considerations for the use of haemodiafiltration 135 .

Box 2 Kidney Heath Initiative Projects that Support Dialysis Innovation

Patient and Family Partnership Council

Since 2015, the Kidney Health Initiative (KHI) Patient and Family Partnership Council (PFPC) has helped KHI stakeholders to engage and network with patients and patient organizations. The PFPC also advises industry and research partners of patient needs and preferences as new products are planned and developed. The PFPC continually emphasizes that innovation will only be successful if built around the needs of people with kidney disease and focused on improving their quality of life.

ESRD Data Standard Project

The aim of this project is to create a harmonized common data standard for kidney failure. The availability of a uniform data standard could accelerate the pace of scientific discovery, facilitate the creation of scientific registries for epidemiological surveillance and allow the development of common metrics for value-based health care.

Building Capacity to Incorporate Patient Preferences into the Development of Innovative Alternatives to kidney replacement therapy (KRT)

This project, which is supported by a 3-year contract with the FDA, is based on the premise that access to scientifically valid patient preference information could positively inform the decisions of industry and regulators as they design and review new devices for individuals with kidney failure. This project will collect patients’ preference information and also address a stated goal of the Advancing American Kidney Health (AAKH) initiative, which instructs the FDA to “develop a new survey to gain insight into patient preferences for new kidney failure treatments” 137 .

Clinical Trial Design to Support Innovative Approaches to KRT

This project is intended to facilitate coordinated efforts between regulators and the nephrology community to streamline the clinical development pathway. The primary objectives of the project are to define terminology for future KRT products (for example, wearable, portable, implantable and artificial kidney) and identify the most appropriate trial designs and end points for a variety of KRT products.

Advancing American Kidney Health

In July 2019, President Donald Trump signed an Executive Order on Advancing American Kidney Health (AAKH) 136 , which promises to fundamentally change the clinical care of kidney disease in general and kidney failure in particular. Components of the AAKH that are relevant to dialysis care include a directive for education and support programmes to promote awareness of kidney disease; a shift in the focus of reimbursement initiatives from in-centre haemodialysis to home therapies, transplantation and upstream CKD care; a system that rewards clinicians and dialysis facilities for providing a range of treatments for kidney failure, with the aim of increasing uptake of home dialysis and transplantation; and incentives for nephrology care teams to focus on reducing costs and improving outcomes by providing longitudinal care of patients with kidney disease.

Finally, and perhaps most radically, the AAKH calls on the US Department of Health and Human Services to support premarket approval of wearable and implantable artificial kidneys and welcomes other strategies to facilitate transformative innovation in dialysis devices. The AAKH directive specifically identifies the KidneyX programme (described below) as the vehicle with which to drive this innovation. The AAKH is the most ambitious US policy initiative ever undertaken to transform the care of patients with advanced kidney disease. Its agenda is still being shaped by the federal governmental agencies, with input from professional societies and other kidney community stakeholders, but this initiative provides a framework and support for transformative innovation in dialysis care.

The KHI Technology Roadmap and KidneyX

The KHI Technology Roadmap for Innovative Approaches to KRT, published in 2019 (ref. 137 ), is aimed at supporting the development of innovative dialysis devices by providing guidance on technical criteria, patient preferences, assessment of patient risk tolerances and regulatory, reimbursement and marketing considerations. Key strengths of the Roadmap include its patient-centred focus and the description of multiple solution pathways for different technologies (for example, portable, wearable and implantable devices that may be purely mechanical, cell-based or hybrid systems), each with appropriate timeline projections.

The KRT Roadmap was designed to be complementary to the Kidney Innovation Accelerator (also known as KidneyX). KidneyX is a public–private partnership between the Department of Health and Human Services and the ASN, and is aimed at accelerating the development of drugs, devices, biologics and other therapies across the spectrum of kidney care. The current major focus of KidneyX is to catalyse the fundamental redesign of dialysis, supported by a series of competitions. Phase I prizes focused on innovations in biomaterials, novel biosensors and safety monitors used for haemodialysis, as well as approaches for improved vascular access and the development of novel technologies that replicate kidney function more precisely than conventional dialysis. Phase II focuses on strategies to build and test prototype solutions or components of solutions that can replicate normal kidney function or improve haemodialysis access. KidneyX has also awarded a series of Patient Innovator Challenge prizes to patients who have proposed innovative solutions to problems emanating from their everyday experiences with kidney disease, including approaches to monitoring blood electrolyte levels and increasing the accessibility of patient education resources.

Dutch Kidney Foundation and Neokidney

The Dutch Kidney Foundation (DKF; or Nierstichting Nederland ) was founded in 1968. It supports research into the causes, prevention and treatment of kidney failure. Furthermore, it works to improve the quality of dialysis treatment and increase the number of kidney transplants. All projects are planned and organized with considerable patient involvement. The DKF also offers financial support to kidney research projects by large Dutch multi-centric consortia. These projects not only promote innovation in the Netherlands but also support trans-national European Union (EU)-supported projects with Dutch participation or leadership, such as Horizon 2020 and Horizon Europe.

Neokidney is a partnership between the DKF and several companies that specialize in miniaturization of dialysis equipment (including dialysis pumps) and sorbent technology for dialysate regeneration. This partnership is aimed at developing a small, portable haemodialysis device that will enable more frequent dialysis sessions, permit more flexibility for patients and improve patient quality of life, as well as reduce health-care costs. The first prototype is currently undergoing preclinical testing and is expected to be tested in humans soon, with the aim of demonstrating proof-of-concept for the first portable haemodialysis machine for daily use, requiring only a limited volume of dialysate. In addition to the development of miniaturization technologies, the partnership is also investigating the use of polymer membranes that permit combined filtration and absorption to achieve more effective haemodialysis 138 .

Nephrologists Transforming Hemodialysis Safety

Nephrologists Transforming Hemodialysis Safety (NTDS) is a collaborative initiative of the ASN and Centers for Disease Control and Prevention (CDC) that is aimed at addressing a specific complication inherent to contemporary dialysis — infection. In 2016, the CDC observed that 10% of dialysis patients in the USA died each year as the result of infections — most of which were preventable. The aim of NTDS is to develop and deploy innovations to achieve zero preventable infections in dialysis facilities across the USA. To reach this goal, NTDS uses a multi-pronged approach. For example, education strategies via publications 139 , 140 , 141 , 142 , 143 and webinars that address various aspects of infection prevention and standards of care, use of social media, development of an interactive chapter for trainees and clinicians, and invited lectures are aimed at ensuring that nephrologists, nurses, dialysis administrators and other professionals understand the risk of dialysis-related infections and evidence-based best working practices.

NTDS also interacts with experts in infection detection, prevention and treatment within federal, state and local health departments who can provide advice and assistance that is independent of the regulatory and potentially punitive arms of health departments. NTDS promotes the appropriate use of these experts in settings where expert advice is needed.

To promote leadership among physicians and nurses, NTDS is sponsoring a leadership academy to ensure that knowledge pertaining to evidence-based best working practices is applied to improve workflows in clinical practice. Effective leadership is a requirement, particularly in complex settings, to ensure that patient safety is prioritized and to motivate staff to use best practices.

NTDS are also collaborating with human factors engineers to study the workflows used in haemodialysis facilities and help to define ways of avoiding errors that lead to infection. As a first step in this process, NTDS and human factors engineers have spent time in various haemodialysis facilities to obtain information about the complex processes of care within those facilities, particularly with regard to the use of haemodialysis catheters and approaches to hand hygiene, injection safety and disinfection. Better understanding of current processes may lead to better workflow design.

Finally, based on lessons learned during the Ebola Crisis of 2014, an NTDS work group has designed processes to anticipate and respond to unexpected health-care crises. At the time of writing this Review, the NTDS team is working with CDC and haemodialysis organizations to anticipate and respond to the COVID-19 epidemic and its effect on dialysis care.

The Affordable Dialysis Prize

As discussed earlier, kidney failure remains a death sentence for many residents of LMICs owing to a lack of access to dialysis. In response to the pressing need for cost-effective dialysis options, the International Society of Nephrology in collaboration with the George Institute for Global Health and the Asian Pacific Society of Nephrology launched the Affordable Dialysis Prize in 2017 with the objective of facilitating the design of a dialysis system that would cost less than US $1,000, and provide treatment for less than $5 a day, yet be as safe and effective as existing dialysis systems. The prize was awarded to an engineer for a system that runs off solar power and includes a miniature distiller for producing pure water from any source via steam distillation. The purified water can then be mixed with electrolytes in empty PD bags to produce cheap, homemade dialysis solutions. This strategy identifies the lack of cheap, high-quality water as a major impediment to dialysis in LMICs and LICs. The system will ideally fit into a small suitcase 144 . This device remains under development with the goal of initiating clinical trials and ultimately commercializing the technology.

Empowered in-centre haemodialysis

For some patients with kidney failure, maintenance in-centre haemodialysis will always be the preferred treatment, and despite incentivizing policy levers, they will not be interested in pursuing home dialysis or kidney transplantation. In-centre self-dialysis (also referred to as empowered haemodialysis) originated in Sweden, when a young engineer named Christian Farman returned to haemodialysis in 2010 after a failed transplant. Farman began negotiating with his nurses to perform his own dialysis treatments with staff supervision and caught the attention of other patients 145 . Eventually, the process of self-dialysis within this centre — whereby coaches in the dialysis unit train people to take over control of their own treatments and health — grew so popular that a new unit was built at the hospital for self-dialysis patients only, with patient input into the design of the unit. Since then, self-care units were installed in several haemodialysis units in Europe and the USA, offering patients the autonomy and flexibility of home haemodialysis within the safety of a controlled environment. This approach to empowering patients has not been widely used to date, but deserves rigorous study and evaluation 146 .

Remote monitoring to support self-care

Telemedicine is defined as the electronic exchange of medical information between sites with the aim of improving a patient’s health. Telehealth encompasses a broader set of services such as the provision of educational content. New technologies have broadened the scope of telemedicine and telehealth applications and services, making these tools more accessible and useful in the care of patients who live remotely or have difficulty visiting a clinic. The range of services that can be delivered by telehealth now includes two-way interactive video, device data programming, asynchronous messaging , sensors for remote monitoring and portals to enable patients to access electronic health records. Although relatively understudied in haemodialysis patients to date, telehealth has the potential to increase the acceptance of home dialysis and improve patient satisfaction, while potentially decreasing costs and improving outcomes.

Telehealth and the remote monitoring of dialysis patients has become more commonplace in the past decade, particularly in Australia, where telehealth is used widely for patients receiving home dialysis. Telemedicine is also considered a support tool for kidney care in disaster situations such as earthquakes where many individuals in remote locations can be affected. Telemedicine has also been used for distance monitoring of patients receiving PD 147 , 148 . In the USA, the Bipartisan Budget Act of 2018 included provisions to expand telehealth coverage to include patients on home dialysis. This legislation allows patients on home dialysis to choose to have their monthly care-provider visits take place via telehealth, without geographic restrictions. The ongoing COVID-19 pandemic has also resulted in an unprecedented and rapid expansion in the use of telemedicine for providing health care in many regions worldwide, including for the care of patients undergoing in-centre haemodialysis. The experience gained during this pandemic has the potential to permanently embed telemedicine in health-care delivery in many health-care systems.

Although telehealth has considerable promise for the care of dialysis patients, the implementation of telehealth in clinical practice can be challenging 149 . Telehealth-guided digital interactions have the potential to improve outcomes through the provision of activities such as individualized patient-centred education, remote communication and data exchange, in-home clinical guidance and monitoring, assessment of prescription and/or treatment efficacy and adherence, real-time modification of treatments and early alerts for problems that require intervention, although all of these interventions need to be rigorously tested 150 .

The European Kidney Health Alliance

The European Kidney Health Alliance (EKHA) is a non-governmental organization based in Brussels, Belgium, which advocates for kidney patients and the nephrology community at relevant bodies of the EU and also at European national organizations. The EKHA represents all of the major stakeholders in kidney care, including physicians, patients, nurses and foundations. The actions of the EKHA are supported by a dedicated group of Members of European Parliament. Of note, according to the treaty of Lisbon 151 , health-care systems are the responsibility of the national authorities of EU countries, which limits the role of the European Commission to one of complementing national policies and fostering cooperation. The EKHA has undertaken several initiatives in the area of kidney care, mainly focusing on measures to decrease the costs of kidney care while maintaining quality of care and access for all appropriate candidates, and to reduce demand for dialysis by promoting efforts to prevent the progression of kidney disease, and encouraging kidney transplantation as the KRT of choice 66 , 152 . In 2021, the EKHA will focus on reimbursement strategies and access to KRT, especially home haemodialysis.

The Nephrology and Public Policy Committee is a similar initiative created by the European Renal Association–European Dialysis and Transplant Association (ERA–EDTA). This committee aims to translate important kidney-related clinical topics into public policy, including the search for novel biomarkers of CKD, improving transition between paediatric and adult nephrology, and improving collaboration between the ERA-EDTA Registry and the guidance body of the ERA-EDTA, European Renal Best Practice 153 .

Beating Kidney Disease

Together with the Dutch Federation for Nephrology and the Dutch Kidney Patients Association, the DKF has initiated a strategic agenda for research and innovation in the Netherlands. This initiative, called Beating Kidney Disease (Nierziekte de Baas) will promote four specific research areas 154 : prevention of kidney failure, including root causes such as other chronic diseases; personalized medicine including genome and big data analyses, and studies of rare diseases; patient-centred outcomes and quality of life, transplantation and home haemodialysis; and regenerative medicine including bio-artificial kidneys. In collaboration with the EKHA, the Beating Kidney Disease initiative will be proposed as a framework for future initiatives at the Directorate General for Health and Food Safety of the European Commission, and the European Commissioner of Health. Similar to European initiatives that have promoted transplantation 152 , 155 , 156 , these efforts will emphasize shifts in policy action to strengthen institutional frameworks, improve education, training and information, optimize registries, and ensure appropriate benchmarking in nephrology.

Conclusions

The past 50 years have seen rapid changes in how and to whom dialysis is provided. From a global perspective, the escalating numbers of patients who require dialysis mean that even current costs are not sustainable, and yet most people who develop kidney failure forego treatment owing to a lack of access, with millions of lives lost every year as a consequence. Also important, the limitations of current dialysis treatment in alleviating patient suffering, morbidity and mortality are now viewed as unacceptable. Consequently, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization to ensure that in the future, people living with kidney failure have more and better treatment options than exist today.

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J.H. declares that The Kidney Research Institute and the Center for Dialysis Innovation at the University of Washington, which he directs, has received gift and grant support from the Northwest Kidney Centers, a not-for-profit dialysis provider. The Center for Dialysis Innovation has also received a Phase I prize from KidneyX, and a grant from the Veterans Administration. J.H. is also a founder and holds equity in AKTIV-X Technologies, Inc. R.V. has consulted for Baxter Healthcare, B. Braun and Neokidney. R.M. has received an honorarium from Baxter Healthcare and serves as a member of the Board of Trustees of the Northwest Kidney Centers. M.T. has received a lecture fee from B. Braun, which was donated to charity.

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Research Article

Good practices for dialysis education, treatment, and eHealth: A scoping review

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Visualization, Writing – original draft, Writing – review & editing

Affiliation Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands

Roles Data curation, Formal analysis, Investigation, Methodology, Resources, Visualization, Writing – review & editing

Roles Conceptualization, Supervision, Writing – review & editing

Affiliations Department of Nephrology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands, Diapriva Dialysis Center, Amsterdam, The Netherlands

Roles Conceptualization, Writing – review & editing

Affiliation Department of Nephrology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands

Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Methodology, Resources, Supervision, Writing – review & editing

* E-mail: [email protected]

• Anita van Eck van der Sluijs, 
• Sanne Vonk, 
• Brigit C. van Jaarsveld, 
• Anna A. Bonenkamp, 
• Alferso C. Abrahams

• Published: August 11, 2021
• https://doi.org/10.1371/journal.pone.0255734
• Reader Comments

Recommendations regarding dialysis education and treatment are provided in various (inter)national guidelines, which should ensure that these are applied uniformly in nephrology and dialysis centers. However, there is much practice variation which could be explained by good practices: practices developed by local health care professionals, which are not evidence-based. Because an overview of good practices is lacking, we performed a scoping review to identify and summarize the available good practices for dialysis education, treatment, and eHealth.

Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words ‘kidney failure’, ‘dialysis’, and ‘good practice’. Relevant articles were structured according to the categories dialysis education, dialysis treatment or eHealth, and assessed for content and results.

Nineteen articles (12 for dialysis education, 3 for dialysis treatment, 4 for eHealth) are identified. The good practices for education endorse the importance of providing complete and objective predialysis education, assisting peritoneal dialysis (PD) patients in adequately performing PD, educating hemodialysis (HD) patients on self-management, and talking with dialysis patients about their prognosis. The good practices for dialysis treatment focus mainly on dialysis access devices and general quality improvement of dialysis care. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life.

Our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients’ contribution in the implementation of their dialysis treatment, and advanced care planning.

Citation: van Eck van der Sluijs A, Vonk S, van Jaarsveld BC, Bonenkamp AA, Abrahams AC (2021) Good practices for dialysis education, treatment, and eHealth: A scoping review. PLoS ONE 16(8): e0255734. https://doi.org/10.1371/journal.pone.0255734

Editor: Sherief Ghozy, Mayo Clinic Minnesota, UNITED STATES

Received: January 30, 2021; Accepted: July 23, 2021; Published: August 11, 2021

Copyright: © 2021 van Eck van der Sluijs et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper.

Funding: This work is part of the DOMESTICO project ‘Good Practices and Shared Decision Making’, which is funded by the ‘Stichting Kwaliteitsgelden Medisch Specialisten’ and Dutch health insurers CZ, Menzis, and Stichting Achmea Gezondheidszorg. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: Anita van Eck van der Sluijs has received speaker honoraria from Baxter Healthcare. Alferso Abrahams has received speaker honoraria from Fresenius Medical Care and Baxter Healthcare. This work is part of the DOMESTICO project ‘Good Practices and Shared Decision Making’, which is funded by the ‘Stichting Kwaliteitsgelden Medisch Specialisten’ and Dutch health insurers (commercial sources) CZ, Menzis, and Stichting Achmea Gezondheidszorg. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Introduction

According to the latest estimates, more than 320 million patients are treated with dialysis worldwide [ 1 ]. In most developed countries, patients start dialysis after having received education on different treatment options (i.e. dialysis, transplantation, and conservative care) [ 2 – 4 ]. Recommendations regarding education and dialysis treatment are given in various (inter)national guidelines [ 5 – 10 ]. These, preferably evidence-based, recommendations assist health care professionals in the guidance and treatment of chronic kidney disease (CKD) patients in order to provide the best possible care.

Guidelines should ensure that complete and objective education is provided to CKD patients about all treatment options [ 5 ]. In addition, guidelines should assure that practical execution of a specific dialysis treatment (i.e. hemodialysis (HD) or peritoneal dialysis (PD)) is more or less the same in all centers. However, this does not always seem to be the case. In 2010, it was shown that variation in center-specific factors (e.g. number of patients, in-center HD treatment capacity, and availability of a late dialysis shift) in the United States influenced the utilization of home dialysis (i.e. home HD and PD) [ 11 ]. This also appears to be true for many other countries when looking at the variation in PD utilization [ 12 ]. In addition, practice variation within a country seems to associate with a broad range in the percentage of dialysis patients treated with home dialysis [ 13 ]. Probably part of this variation can be explained by so-called ‘good practices’ which are developed locally.

The term ‘good practice’, also referred to as ‘best practice’, denotes ‘… a practice that has been proven to work well and produce good results , and is therefore recommended as a model . ’ [ 14 , 15 ]. Good practices are practices that are developed locally and with which health care professionals have good experience, but are not evidence-based and therefore not added to (inter)national guidelines [ 14 , 15 ]. As a result, these practices are not distributed and applied nationally, such as the recommendations from (inter)national guidelines. Although not evidence-based, good practices can have additional advantages and are therefore worthwhile exploring. Moreover, local good practices for dialysis education and treatment could potentially explain the previously mentioned practice variation.

An overview regarding these good practices is lacking in current published literature. Thus, we performed a scoping review to identify and summarize the available literature describing good practices for dialysis education, treatment, and electronic health (eHealth).

Search strategy and selection criteria

Embase, Pubmed, the Cochrane Library, CINAHL databases and Web of Science were searched for relevant articles using all synonyms for the words ‘kidney failure’, ‘dialysis’, and ‘good practice’ ( Table 1 ).

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https://doi.org/10.1371/journal.pone.0255734.t001

After removal of duplicates, two authors (AES and SV) independently screened titles and abstracts. Articles were eligible for inclusion if they provided a thorough description of the content of a good practice regarding dialysis education, treatment or eHealth for adult patients. Articles of all study types were included, however articles that described a guideline, review or meta-analysis were subsequently excluded after being screened for additional references.

Articles were excluded if they referred to a practice already covered in (inter)national guidelines, or if they reported on implementation projects, diabetes mellitus care or exercise programs for dialysis patients. In addition, articles were excluded if no full text or only a published abstract was available or if they were written in a language other than English.

The remaining articles were read full text by two authors (AES and SV) and screened for additional references. Final inclusion was based on consensus between the two authors (AES and SV) based on the previously mentioned in- and exclusion-criteria. In case of disagreement, the opinion of a third author (ACA) was decisive.

Data extraction

Data extraction was executed and checked by two authors (AES and SV). The included studies were structured according to the category to which the good practice was related. The following categories were used: dialysis education, dialysis treatment, and eHealth. After classifying the articles in the aforementioned categories, the following data were extracted: study design, number of participants investigated, good practice description, results, and study conclusion.

Study selection

The initial literature search was performed on May 2, 2019, and last updated on January 12, 2021. Fig 1 provides an overview of the search. After removal of duplicates, the search provided 5,213 articles. Subsequently 5,109 articles were excluded based on the title and another 74 were excluded based on the abstract. The full-text of the remaining 30 articles was assessed for eligibility. In total, 17 articles were excluded for the following reasons: no good practice described [ 5 , 16 – 20 ], content of the good practice not described [ 21 – 24 ], good practice not regarding dialysis education or dialysis treatment [ 25 ], articles describing a guideline [ 26 , 27 ] or review [ 23 , 28 – 30 ]. The remaining 13 articles were screened for additional references, resulting in 6 cross-references ( Fig 1 ) [ 31 – 36 ]. No additional cross-references were found in the articles describing guidelines, reviews or meta-analyzes. So, in total 19 articles were included [ 31 – 49 ].

* Exclusion criteria for title screen: No good practice regarding dialysis modality education/treatment or eHealth, implementation project, diabetes mellitus care or exercise program for dialysis patients, guideline, meta-analysis, protocol, review, and language other than English.

https://doi.org/10.1371/journal.pone.0255734.g001

Study characteristics

Characteristics of the 19 included articles are presented in Tables 2 – 4 . Twelve articles described good practices for dialysis education ( Table 2 ), three for dialysis treatment ( Table 3 ), and four for eHealth ( Table 4 ). All articles were published during the past 20 years and 47% of them came from the United States of America (USA). Most studies (58%) had a qualitative design, while the others were cohort studies (21%), case-control studies (11%), and randomized controlled trials (11%).

https://doi.org/10.1371/journal.pone.0255734.t002

https://doi.org/10.1371/journal.pone.0255734.t003

https://doi.org/10.1371/journal.pone.0255734.t004

Dialysis education

Four of the twelve articles that described good practices for dialysis education, focused on providing objective predialysis education for CKD patients ( Table 2 ) [ 31 , 32 , 40 , 45 ]. Fortnum et al . [ 40 ] presented the ‘My Kidneys, My Choice’ decision aid, a patient-centered tool to support the education of CKD patients and promote shared decision making. Health care professionals found the decision aid to be helpful for understanding treatment options and patients’ priorities, and for supporting decision making.

Lacson Jr. et al . [ 31 ] initiated a standardized predialysis treatment options education program that consisted of education provided during a single group class session, followed by contacts after 30, 90, and 180 days during which treatment options were repeatedly discussed. Compared to controls, patients who followed the standardized education program were significantly more likely to choose PD (odds ratio (OR) 5.13) or to start in-center HD with a fistula or graft (OR 2.06), and had a lower mortality (OR 0.61) during the first 90 days of dialysis treatment [ 31 ].

Manns et al . [ 32 ] developed a two-phase patient-centered educational intervention, showing manuals and a video for self-care dialysis (i.e. PD, home HD, and self-care HD) in phase 1 and conducting a small group session in phase 2. The intervention significantly increased the proportion of patients who intended to initiate self-care dialysis (intervention group 82.1% vs. standard care group 50%).

Wu et al . [ 45 ] presented a multidisciplinary predialysis education program consisting of quarterly individual nurse-led lectures for CKD patients stage 3 and 4, while this was intensified to monthly lectures for CKD patients stage 5. Compared to controls, patients who followed the multidisciplinary education program had a significant lower risk of requiring dialysis (hazard ratio (HR) 0.117) and lower mortality (HR 0.103) after a mean follow-up of 11.7 months.

Five of the twelve articles that described good practices for dialysis education, focused on PD patients [ 33 , 37 – 39 , 41 ]. Luongo et al . [ 41 ] described a five-step approach (i.e. preparation, environment, special considerations, interview, and special concerns) for nurses to interview CKD patients who may choose PD as dialysis treatment. The goal of the interview was to reduce stress and anxiety in the patient and to promote shared decision making. Although this approach has not been tested, the authors concluded that it guides PD nurses in providing correct information to future PD patients without overwhelming them.

The qualitative studies of Figueiredo et al . [ 38 ] and Firanek et al . [ 39 ] focused on PD training. Figueiredo et al . [ 38 ] provided a detailed description of a 5-day PD training course, with an introduction on day 1, supervised procedure practice sessions on days 2 to 4, and a review of the provided information and check of the patient’s competence on day 5. The authors concluded that with this training course PD nurses ensure that the patient can perform PD safely and effectively. Firanek et al . [ 39 ] visited six centers to identify successful components of the PD training programs. Subsequently, they provided an overview of these successful components focused on setting and staff, training methods, educational documents, training structure, automated peritoneal dialysis (APD) training content, and delivery of APD training.

Successful home visit programs were described by Farina et al . [ 37 ] and Martino et al . [ 33 ]. The main similarities between the two programs were: assessment of the home where PD was performed, assessment of the PD procedure performed by the patient, and the patient’s compliance to pharmacological and dialysis therapy. While Farina et al . did not examine the effect of the intervention, Martino et al . reported that PD patients who received a home visit had a significantly longer PD duration (52 weeks) and a lower technique failure rate (11.5%) compared with controls (PD duration 48.8 weeks, technique failure rate 23.3%) [ 33 ].

The last three articles focused on an educational program for HD patients [ 44 ] and conversations with dialysis patients [ 42 , 43 ]. Wingard et al . [ 44 ] described a 3-month educational program for HD patients that focused on health self-management, rehabilitation, nutritional counselling, and interventions for achieving goals such as anemia management, adequate dialysis dose, logistical, and psychosocial support. Compared to controls, patients who completed the program had significantly fewer hospitalization days per patient year (7.2 vs. 10.5) and a lower mortality (HR 0.59) after a maximum follow-up duration of 12 months. The authors concluded that the program not only reduced morbidity and mortality, but also increased job satisfaction for nurses.

Mandel et al . [ 42 ] described a 6-step guide for serious illness conversations with dialysis patients to discuss their prognosis. The guide consisted of the following steps: set up the conversation, assess the patient’s illness understanding, share the patient’s prognosis, explore key topics, close the conversation, and document the conversation. The article by Michel et al . [ 43 ] also described an approach for talking with dialysis patients about their prognosis based on four aspects: who to tell, when to tell, what to tell, and how to tell. The authors concluded that this approach can help discussing prognosis with dialysis patients, taking into account the patient’s preferences.

Dialysis treatment

The three articles that described good practices for dialysis treatment were all qualitative studies ( Table 3 ) [ 46 – 48 ]. Abdel-Aal et al . [ 46 ] provided a detailed description of the procedure for insertion of a PD catheter by interventional radiologists. Various aspects of pre-procedure preparation, such as bowel preparation and fasting, were discussed followed by a detailed explanation of the PD catheter insertion with explanatory photos. The procedure was described as a cost-effective and minimally invasive alternative to traditional surgical placement of a PD catheter.

Craswell et al . [ 47 ] described practices for insertion, maintenance, and removal of central venous catheters (CVCs) for HD. The practices for insertion consisted of patient education for insertion, anatomical site selection and decision-making, and training. The practices for maintenance consisted of education, dressing practices, and assessment and monitoring for infection. The practices for removal consisted of the decision for removal and complications of removal. The authors concluded that an interdisciplinary team is very important for patient education and catheter care.

Desai et al . [ 48 ] reported 155 good practices that could potentially improve outcomes of dialysis centers, such as dialysis dose and anemia management, and overall survival in dialysis patients. The 155 good practices were divided into the following domains: facility characteristics and amenities, facility-based health maintenance, staff working climate, general dialysis care practices, physician practices, nursing practices, technician practices, and miscellaneous practices. Through a survey among 342 respondents, a top 30 of good practices that had the most impact on overall outcomes in dialysis was compiled. The majority of the top 30 good practices focused on conducting a successful multidisciplinary team meeting, performing audits, training nurses, reviewing the performance of health care professionals, and enhancing communication and teamwork.

Four articles described good practices for eHealth, one of which focused on HD [ 49 ] and three on PD ( Table 4 ) [ 34 – 36 ]. The qualitative article on PD by Kaldoudi et al . [ 34 ] described the components of an eHealth system by which data could be collected such as PD method, prescription, body weight and hearth rate. Viglino et al . [ 36 ] described an eHealth system which led to a reduction in peritonitis episodes and a 17.6% reduction in the number of transfers from PD to HD because reduced compliance or lack of availability of a caregiver was no longer an issue. The authors concluded that this system can be a valuable tool for increasing the number of PD patients.

While Kaldoudi et al . [ 34 ] and Viglino et al . [ 36 ] focused more on the technical aspects of eHealth systems for PD patients, Li et al . [ 35 ] conducted a randomized controlled trial to investigate the effect of post-discharge telephone support for PD patients. Patients were included if they performed PD for a minimum of 3 months and were admitted to a nephrology department. The control group received routine care, while patients in the intervention group were visited by a nurse who assessed their needs and provided individualized education. After discharge from the hospital, the nurse called the patients from the intervention group every week during a period of 6 weeks to assess their status and to give advice. This approach led to a significant improvement of several health-related quality of life domains (e.g. symptoms, energy, work status) and a reduction in the number of hospital visits.

Finally, Sicotte et al . [ 49 ] reported two eHealth models for in-center HD patients: virtual patients rounds and telecase reviews with a multidisciplinary team. During the virtual patient rounds, a remote nephrologist and nurse had contact with a patient and his/her nurse at the dialysis center. During the telecase review, a remote nephrologist and nurse had contact with the general practitioners and nurses at the dialysis center via videoconference, without the patient being present. Both models led to a significant reduction in the number of medication changes per month during a follow-up of 2 years. The authors concluded that eHealth can provide distant supervision which improves the level of care utilization.

This scoping review identifies 19 articles with good practices that could be used in addition to guidelines. The twelve articles with good practices for dialysis education endorse the importance of providing complete and objective predialysis education to CKD patients, assisting PD patients in performing PD adequately, educating HD patients on self-management, and talking with dialysis patients in general about their prognosis. The three articles with good practices for dialysis treatment provide practices regarding dialysis access devices and numerous candidate good practices for dialysis centers. Finally, eHealth is useful for HD and PD and affects both quality of care and health-related quality of life.

Good practices are locally implemented practices with which health care professionals have good experience, but which are not necessarily evidence-based [ 14 , 15 ]. Therefore, they are generally not added to (inter)national guidelines. For dialysis treatment, there are many guidelines with proven treatment methods, while guidelines for dialysis education are scarce [ 10 , 52 ]. This probably explains why we have found many good practices for dialysis education and only a few for dialysis treatment.

Six of the 12 articles regarding dialysis education report a positive effect of the described good practice(s) [ 31 – 33 , 40 , 44 , 45 ]. Complete and objective education to CKD patients by a multidisciplinary team decreases the dialysis incidence and mortality [ 45 ]. Moreover, it increases the use of home dialysis [ 31 , 32 ]. The European Renal Best Practice (ERBP) Advisory Board also underscores complete and objective education to enable CKD patients to choose a dialysis modality that is most suitable for them [ 5 ]. Another useful good practice is a decision aid for CKD patients, which supports the shared decision making process according to health care professionals [ 40 ]. A Cochrane review, describing 105 decision aids for patients facing various treatment or screening decisions, also states that decision aids increase participants’ knowledge, decrease decisional conflicts, and facilitate active participation in decision making [ 53 ]. However, the review includes no decision aids specifically for nephrological care. A randomized study among 133 CKD patients concludes that an online decision aid can improve knowledge and decrease decisional conflict and uncertainty about choice of dialysis treatment [ 54 ]. So, decision aids are important for use during dialysis education.

A home visit also seems to be a very relevant tool for PD education, since Martino et al . [ 33 ] report that their home visit reduces technique failure and extends PD treatment. The positive effect of a home visit is also found in a French study of 359 patients on assisted PD, which found that it increases the probability of patients remaining peritonitis free from 33.9% to 50.8% at 3 years (p = 0.028) [ 55 ]. Home visits conducted in two other studies, with the aim of providing dialysis education for CKD patients, result in a higher probability for patients to receive home dialysis [ 56 , 57 ]. So, home visits seem to be important not only for PD patients, but also for CKD patients who have yet to make a treatment choice.

The articles regarding dialysis treatment provide guidance on PD catheter placement by interventional radiologists and the insertion, maintenance, and removal of CVCs [ 46 , 47 ]. The International Society for Peritoneal Dialysis (ISPD) guideline on peritoneal dialysis access only briefly mentions image-guided percutaneous PD catheter placement [ 58 ], so the procedure described by Abdel-Aal et al . can be a relevant addition [ 46 ]. The (inter)national guidelines for CVCs also describe insertion, maintenance, and removal practices [ 59 – 61 ], however only the most recent guideline [ 62 ] underscores the importance of patient education as Craswell et al . did [ 47 ]. Finally, the 155 candidate good practices reported by Desai et al . could lead to general quality improvement of dialysis care [ 48 ].

The articles regarding eHealth show that this good practice improves quality of care for HD patients [ 49 ], quality of life for PD patients [ 35 ], and reduces the number of peritonitis episodes [ 36 ]. In 2017, Rosner et al . [ 63 ] conducted a review on the use of eHealth in the care for dialysis patients. They found 19 articles describing mostly small, single-center studies published between 1999 and 2017, 13 articles for PD and 6 articles for HD. Most of the articles used video conferencing, remote monitoring, or monthly visits with physical examination (e.g. electronic stethoscopes) using eHealth as technology. All articles report positive results of their eHealth system on various outcomes such as patient independence, quality of life, and hospitalization. Rosner et al . conclude that there still is a lack of evidence regarding the use of eHealth, however they mention possible benefits for example increased uptake and acceptance of home dialysis, treatment monitoring in the home environment, improved patient satisfaction, and potential for cost savings [ 63 ]. In the current time with the coronavirus disease 2019 (COVID-19) pandemic, eHealth may play an important role through, for example, video conferences and remote patient monitoring [ 64 – 66 ].

Our review has several limitations. First, there is a probability that we have not identified all articles describing good practices. This is partly because many articles do not label their practice as ‘good practice’, making them less likely to appear in the search. However, by also using ‘best practice’ and ‘practice guidelines’ as a search topic, we believe that we have attenuated this problem. Second, most of the studies are qualitative in nature and describe no results, making it impossible to determine an effect of the described good practices. Finally, most of the studies that described results investigate a small number of patients and report on different outcomes, making mutual comparison impossible.

In conclusion, our scoping review identifies 19 articles describing good practices and their results for dialysis education, dialysis treatment, and eHealth. These good practices could be valuable in addition to guidelines for increasing shared-decision making in predialysis education, using patients’ contribution in the implementation of their dialysis treatment, and advanced care planning. Good practices can inspire and support health care professionals to change their practices and this could possibly help to improve outcomes and quality of life for CKD and dialysis patients. Additional research on good practices could be useful to identify more good practices and determine the impact of these practices on CKD and dialysis patients.

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• 2 Temple University, Lewis Katz School of Medicine
• PMID: 33085443
• Bookshelf ID: NBK563296

The term dialysis is derived from the Greek words dia, meaning "through," and lysis, meaning "loosening or splitting." It is a form of renal replacement therapy, where the kidney's role of filtration of the blood is supplemented by artificial equipment, which removes excess water, solutes, and toxins. Dialysis ensures the maintenance of homeostasis (a stable internal environment) in people experiencing a rapid loss of kidney function, i.e., acute kidney injury (AKI) or a prolonged, gradual loss that is chronic kidney disease (CKD). It is a measure to tide over acute kidney injury, buy time until a kidney transplant can be carried out, or sustain those ineligible for it.

The incidence of renal replacement therapy (RRT) depends on the incidence and prevalence of conditions causing end-stage renal disease (ESRD), early diagnosis of chronic kidney disease (CKD), and measures to slow the progression to end-stage renal disease (ESRD). Systematic identification of patients with a declining estimated glomerular filtration rate (eGFR), heavy proteinuria, and history of acute kidney injury episodes facilitates planned RRT commencement, thus slowing the rising trend in emergency RRT incidence. All patients likely to end up with ESRD and their caregivers must be adequately prepared physically and psychologically and provided with accessible education about future treatment options. Advanced preparation helps avoid dialysis-associated complications such as a malfunctioning catheter or poorly functioning fistula, causing temporary vascular access insertion culminating in sepsis, thrombosis, bleeding, and accelerated mortality. Patients with educational programs are more likely to choose home-based dialysis therapy with societal benefits, less expenditure, and improved quality of life. These programs should commence no later than stage 4 CKD for the patient to have sufficient time and cognition to make informed choices and implement preparatory measures for RRT.

In 2010, approximately 2.5 million people worldwide received chronic RRT, with high absolute rates in North America and maximum prevalence in Taiwan and Japan. Maintenance of regional and national dialysis registries with details on rates, outcomes, and national dialysis practice patterns helps keep track of the population dependent on RRT. They also include hospital-specific information, safety, and quality reporting and provide resources for clinical research. Opting for dialysis is affected by sociocultural and socioeconomic factors. ESRD is disproportionately higher in African Americans and CKD among the White population. ESRD burden is attributed to diabetes mellitus (45%) and hypertension (30%), besides rarer causes like polycystic kidney disease, obstructive nephropathy, and glomerulonephritis. Women are at higher risk for CKD, while men have a higher risk of ESRD. Race disparities can limit access to health care due to their impact on income or the availability of health insurance. Indigenous people in Australia, New Zealand, the United States, and Canada have high rates of kidney disease, less access to transplantation, and poorer outcomes. There are three broad types of dialysis:

Hemodialysis (HD)

Peritoneal dialysis (PD)

Continuous renal replacement therapy (CRRT)

The dynamics of this particular form of renal replacement therapy vary across countries with longer dialysis sessions and slower blood flow rates in Japan. PD is highly prevalent in Hong Kong and the Jalisco region of Mexico, while Home HD is widely adopted in New Zealand and Australia.

The timing for initiation of dialysis is decided after considering the complications of early initiation (unnecessary exposure to IV lines and invasive procedure with risks of infection) against late initiation, causing avoidable volume, metabolic, and electrolyte complications of AKI. Assigning arbitrary urea nitrogen or creatinine level for dialysis initiation is not advisable due to individual variability in uremia symptom severity and renal function. Despite optimal CKD management, patients progress to needing RRT, especially when their eGFR drops below 20 ml/ min/1.73 m2 or they rapidly deteriorate to ESRD within 12 months. The eGFR at dialysis initiation has steadily increased in recent times. In 1996, in the United States, 13% of incident ESRD patients started RRT at an eGFR of 10 ml/min/1.73 m2 or higher. This increased to 43% in 2010 and dropped to 39% in 2015. Waiting for uremic symptoms to set in before commencing RRT had added risks of the patient being malnourished with increased mortality risk. Asking patients to compare their current eating habits and physical activity levels with those 6 to 12 months back helps avoid the lack of awareness. The concept of a 'healthy start,' with dialysis commencing before the onset of severe uremia symptoms, is associated with prolonged survival. An early start will prepone the need for a change of modality or further procedures without any improvement in the quality of life while adding to healthcare costs. The Renal Physicians Association's (RPA) criteria for identifying dialysis patients with a poor prognosis beyond 75 years of age includes:

Provider's estimation of the likelihood of patient mortality in the next six months

Greatly impaired functional status

High comorbidity score

Severe chronic malnutrition (low serum albumin)

Quality of life also strongly predicts mortality. It provides a comprehensive toolkit to encourage shared decision-making.

Mortality rates among dialysis patients are markedly higher among younger age groups, primarily attributed to cardiovascular (40%) and infectious causes (10%). High cardiovascular mortality in dialysis patients could be related to shared risk factors such as chronic inflammation, significant changes in extracellular volume, dystrophic vascular calcification, and altered cardiovascular dynamics during dialysis. The study of heart and renal protection (SHARP) having dialysis and non-dialysis requiring CKD patients showed a 17% reduction in cardiovascular death and major cardiovascular events with simvastatin-ezetimibe treatment. Cardioprotective strategies such as beta-blockers, aspirin, and renin-angiotensin-aldosterone system inhibitors are recommended in dialysis patients based on their cardiovascular risk profile. Hypertension has a graded association with ESRD risk as it is both a cause and a consequence of CKD. The first three months after dialysis initiation, especially among older patients, has the highest mortality rates. This could be due to risks associated with the commencement of dialysis (central venous catheter placement) and more severe comorbidities causing deterioration of renal function. Effective interprofessional collaboration is needed to improve overall outcomes in patients with ESRD requiring dialysis.

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Conflict of interest statement

Disclosure: Himani Murdeshwar declares no relevant financial relationships with ineligible companies.

Disclosure: Fatima Anjum declares no relevant financial relationships with ineligible companies.

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• Published: 26 November 2018

The lived experiences of patients undergoing hemodialysis with the concept of care: a phenomenological study

• Nahid Shahgholian 1 &
• Hojatollah Yousefi 2  

BMC Nephrology volume  19 , Article number:  338 ( 2018 ) Cite this article

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Providing patient-centered care needs in patients with chronic renal failure undergoing hemodialysis is important in inspiring their confidence to continue their treatment and promote their mental and social health. Therefore, recognizing the concept of care from the viewpoint of these patients can be helpful in designing the care programs of this vulnerable group. Accordingly, the aim of this study was to reveal the meaning and concept of care based on the experience of patients with chronic renal failure undergoing hemodialysis.

Using a descriptive phenomenological method, this study was conducted on 17 patients who were undergoing hemodialysis. Purposive sampling was performed and data was collected through 30 to 60 min, face-to-face and in-depth semi-structured interviews. Data analysis was performed using Colaizzi’s method.

Seventeen patients (9 women 8 men) aged between 24 and 83, and a minimum of 10 and maximum of 168 months history of hemodialysis participated in the study. After data analysis, 4 themes and 9 sub-themes were extracted, and the concept of care emerged for the participants as empathy, companionship in everyday needs, social support and concern, and good-quality dialysis.

Conclusions

Based on the results of this study, the concept of care from the viewpoint of patients emerged in the form of empathy, companionship in everyday needs, social support and concern, and good-quality dialysis. It is recommended that caregivers of patients consider these concepts in the design of patient-centered care programs.

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Hemodialysis is the most common treatment for the end-stage chronic renal failure in Iran and in the world [ 1 ], so that by the end of 2016, the number of patients undergoing dialysis is estimated to be 2,989,000, 89% of which are hemodialysis patients. In Iran, by the end of 2016, the number of patients undergoing hemodialysis has been estimated to be 29,200 [ 2 ]. Hemodialysis increases patients’ longevity but, at the same time, imposes many restrictions on these patients and leads to many physical, mental, social and economic complications. Minimizing these complications need a comprehensive care for these patients.

Care is divided into three groups of professional care by the health care team including nurses, home care by the family members, and social care. However, regardless of who provides the care, there is still no specific meaning for this concept which can be used in all situations [ 3 ]. Additionally, in spite of the care provided by the health care team, family and society to these patients, they still believe that they don’t receive enough care [ 4 ]. The word “care” has many meanings in Persian, such as the provision of what is necessary for the health, welfare, maintenance, protection, attention, guard,, lookout on, and watch of someone. Accordingly, it seems that the point of view of the patients towards this concept is different from the caregivers. Any successful planning and intervention for these patients need to familiarity with this concept based on the lived experience of the hemodialysis patients. The reason is that receiving this concept from the viewpoint of patients can develop the care provided for them and, using this concept, the care team can design a realistic patient-centered care plan and provide an effective intervention.

Many conducted studies have focused on how to care for these patients in order to reduce the complications of disease and treatment, increase the quality of life, reduce stress and improve the mechanisms of compatibility in these patients. However, none of these studies have investigated or considered the viewpoint of patients [ 5 , 6 ]. Shafiee et al. compared the barriers of blood glucose monitoring in diabetic patients from the viewpoint of patients, healthcare staff and family of the patients. They found significant differences and argued that such difference or disagreement results in the failure of diabetes control in these patients [ 7 ].

Atashzadeh et al. also compared the concept of nursing quality in the group of patients, doctors and nurses. In this study, the researchers emphasized the disagreements among these three groups and believed that these disagreements made the healthcare staff not be able to improve the quality of care expected by the patients and, hence, the patients were not satisfied with the quality of the provided care [ 8 ]. Because of having a different treatment process, patients undergoing hemodialysis have a different experience of the concept of care. However, studies that investigated the experience of patients undergoing hemodialysis [ 9 , 10 ] did not cover the concept of care from the viewpoint of the patients and based on their experiences. Accordingly, it seems that conducting a qualitative research in this area, through a deep understanding of the concept of care from the viewpoint of the patients and their experience of care, can help approaching the view of the patients to that of professional, home and social caregivers. It also improve the quality of care, increase the effectiveness of care, provide better services, and promote the patients’ health and quality of life.

Phenomenology is one of the qualitative research methods suitable for understanding the depth of experience and the concept of a phenomenon [ 11 , 12 ]. According to Thorne (2016), phenomenology is a good method for discovering obscure concepts, including the concept of care, in nursing and other health-related professions [ 13 ]. Accordingly, using the descriptive phenomenological method, the researcher decided to investigate the concept of care from the viewpoint and based on the experiences of the patients with chronic renal failure undergoing hemodialysis.

Given its purpose of revealing the meaning and concept of care based on the experience of the patients with end-stage renal disease undergoing hemodialysis, this study was a qualitative research with descriptive phenomenological method. This method is used to study experience and describe the concept from the perspective of patients who have lived with the illness, and creates a comprehensive description of the experienced phenomenon in order to achieve an understanding of its essential structure and, beyond its description, provides an interpretation of the phenomenon [ 11 ]. Seventeen patients with end-stage renal disease, with purposive sampling, participated in the research. Inclusion criteria: at least three month have elapsed from the start of hemodialysis, no speech and hearing problems, speak fluent Persian, undergo hemodialysis in the hemodialysis unit of Al-Zahra hospital affiliated to Isfahan University of Medical Sciences, Isfahan, Iran, and have a fixed and active medical file in this unit. This unit covers 40 patients permanently. The patients were interviewed one day after dialysis time, in a stable condition, in a room that in an agreement with all patients had been selected next to the dialysis unit. Sampling began from October 23, 2015 and continued to reach saturation, when no new code was extracted, on February 20, 2016.

In order to collect data and access valid and real information, a semi-structured in-depth interview (face-to-face) was used as the main approach. Each interview lasted for 30–60 min.

Each interview started with general questions and was followed up with a calm and flexible format. The interview process actually depended on the respondents’ level of participation. A few questions were used as the interview guide (Table  1 ). At the same time, some exploring questions such as “could you please explain it more?” or “can you clarify what you mean with an example?” were asked to achieve rich and clear data.

The first researcher then heard each recorded interview several times and transcribed to verbatim and gave a number to each interview. In the same time, using Colaizzi’s seven-step approach, data analysis was performed as follows. 1) The descriptions of the participants were repeatedly read in order to feel them out; 2) 200 important expressions were extracted and numbered; 3) Important expressions were written in scientific language and the meanings were formulated; 4) The constructed concepts/themes were grouped based on their similarity; 5) Nine sub-themes were formed; 6) Similar sub-themes were organized in larger clusters and four main themes were obtained; 7) In order to ensure the accuracy of his/her impressions, the researcher returned them again to the participants, but there was no need to review and repeat the interviews. The researcher reached the data saturation after 17 interviews.

To evaluate validity and reliability of the data, Guba and Lincoln evaluative criteria were used [ 14 ]. Accordingly, in order to make the research believable, the review of the co-researchers and participants was also used.

Likewise, to ensure the reliability of the data, after hearing, and analyzing the interviews, the peer review, PhD in nursing, reread and refined the data. The research team used the described methods to minimize the influence of their pre-existing ideas and beliefs on the current research findings.

To provide transferability in this research, the researcher used the full introduction of the research, described the background and stages of the research fully and tried to choose samples in maximum variations.

This research was approved by the Ethics Committee of Isfahan University of Medical Sciences No. 293333. After receiving the necessary permission from the university, the researcher entered the research site. While introducing herself and providing the necessary information to the patients, the researcher explained the purpose and process of the research. After filling out the written informed consent form, the time and place of the interview was determined by an agreement between the participants and the researcher. During the interview, feedback and oral consent were also obtained. Additionally, to maintain anonymity, each interview was given a number. Before beginning the interviews, the participants’ permission was obtained, and they were assured that their names and information would remain confidential. The participants had the absolute discretion to leave the study whenever they wished.

Seventeen patients (9 female and 8 male) aged between 24 and 83, and minimum of 10 and maximum of 168 months of treatment duration participated in the research. In terms of education, the participants ranged from illiterate to master’s degree; seven were married and their spouses took care of them; and, diabetes was the most common underlying disease causing chronic renal failure (Table  2 ).

Analyzing interviews, 200 inferential codes, 9 sub-themes and 4 main themes were extracted. From the perspective of the hemodialysis patients, the care phenomenon was defined through the formation of concepts such as empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis.

The concept of empathy was shaped by the feeling of receiving psychosocial support from the treatment team and emotional support from the family. Help with daily activities and the provision of adequate nutrition were the sub-themes that formed the theme of accompaniment in meeting daily needs. Social support and concern, was another theme that, in explaining the phenomenon of care, was formed by a sense of society’s understanding of the patient’s condition, provision of employment opportunities and financing. High-quality dialysis was another theme which included the sub-themes of meticulous care during dialysis and advanced or unbroken dialysis machine (Table  3 ).

Emotional support

Because of numerous dialysis sessions, the participants spent a lot of time with healthcare staff including nurses and doctors. As such, they expected the medical staff to support them psychologically and emphasized their empathy:

‘When nurses listen to me, I’m sure they care for me.’ (Participant 5)

‘When I was hospitalized for my heart condition, I’d like to visit the staff of my own ward (hemodialysis); I was very alone.’ (Participant 7)

Emotional support of the family was another extracted concept and participants stated that emotional support of family members is an integral part of care:

‘I’d like my wife and my children to listen to me and spend more time with me; when they are with me, I’m not afraid of the disease.’ (Participant 3)

What the statements of the participants implied was that the empathy of the health staff, especially the nurses, and the emotional support of family members made the patients feel secure and less worried and, thus, they considered empathy as a concept of care.

Accompaniment in meeting daily needs

The participants stated that because of their old age, underlying diseases, fatigue and boredom, they often need the help and support of their family for doing daily activities including healthcare activities:

‘I have a blurred vision and can’t see clearly; I can’t shave my face or trim my fingernails; my wife or my children have to do these for me.’ (Participant 10)

Providing an adequate nutrition by the family was another sub-theme of accompaniment in meeting daily needs. Because of their illness, nutritional restrictions are necessary for these patients, and because of their physical conditions, the provision of a special diet requires the collaboration and support of their family:

‘My wife knows which kinds of foods contain phosphorus and potassium, and when it comes to cooking, she is careful and controls my regimen; I can’t do it myself.’ (Participant 2)

‘My family should make me a meal, I can’t do it myself’ (Participant 3)

Participants’ statements indicated that family accompaniment was essential for daily activities such as providing personal health and support in going on a diet. Hence, in the opinion of the participants, accompaniment was one of the concepts of care.

Social support and concern

Increasing the society’s understanding of the condition of the patients was another theme. The patients expressed their dislike of the pity of others and stated that they wanted others to understand them. Thus, instead of pity that might annoy them, they expected others to help and support them when necessary:

‘People don’t understand us; if they did, they would, for example, give up their seat to us in the bus, or give us they turn in the pharmacy or doctor’s office.’ (Participant 12)

‘Everyone is very busy and there is no support. Many people pity us but I don’t like it.’ (Participant 10)

Providing job opportunities and financing were the sub-themes emphasized by the participants. Because of frequent dialysis sessions, job loss, insufficient ability to work hard and continuously, medical expenses, transportation costs and disproportion between income and treatment or life costs, the patients had economic problems. As such, they believed that having a suitable job and being secured financially is a kind of care:

‘I lost my job because of dialysis; charity doesn't help much; I wish the association helped more and the insurance covered the cost of all drugs; or at least we could have a good job.’ (Participant 3)

Participants’ remarks implied that the society has to change its attitude towards the condition of these patients. As the lack of an organized program to support patients has led to a lot of economic problems for them, providing a job in proportion with the physical condition and dialysis time of these patients can help them benefit from a systematic economic support.

High-quality dialysis

Since hemodialysis is very sensitive process, patient care and control during dialysis is important. Thus, a meticulous care during dialysis is highly important for the participants:

‘Some personnel don’t set up the machine based on my condition and my blood pressure drops.’ (Participant 7)

‘Every time during dialysis they control my blood pressure five times; I’m afraid of drops in my blood pressure during dialysis; I have spasm in my legs.’ (Participant 13)

An unbroken or advanced dialysis machine was another issue that the participants referred to and stated that a high-quality dialysis is almost impossible without a well-functioning dialysis machine:

‘The machines are broken and don't lose weight well; we’re thirsty between two dialysis; we drink water and get short of breath; our pressure drops under the dialysis; they disconnect us quickly from the machine and going home we are not well.’ (Participant 4)

Accordingly, the participants considered high-quality dialysis as a part of care and emphasized the importance of a meticulous care during dialysis and the proper functioning of the dialysis machines.

Based on the results of the research, the lived experience of dialysis patients shows that care for these patients means empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis. These concepts thus have to be considered in the care plans designed for these patients by the medical staff, domiciliary caregivers and social agents.

The four main themes of emotional support, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis were considered by the participants as the concepts of care; and, it seems that the participants of the present study emphasized the psychological aspects of care more than its physical aspects.

The results of the study conducted by Georgia showed that most hemodialysis patients suffer from a heavy burden of psychological problems [ 15 ].

The empathy of the medical staff was one of the concepts of care and the participants emphasized the effectiveness of the relationship with the nurses and doctors and remarked that this relationship can be soothing and reassuring for them. Davison and Simpson believe that the role of personnel in communicating with the patients and their family is very important and can raise their hope. They argue that the nurse’s speaking to the patients about their situation can sometimes be the source of relief and hope for the health and well-being of the patients [ 16 ].

The participants’ statements in the present research suggested a significant role of the empathy of the family members in the care and support for the patients. In this regard, a research has shown that family members, especially one’s spouse, have the most important role in providing mental health services to a patient with chronic illness. The patients considered their spouse as the key person in supporting them, that is, the support of the patient’s spouse was the most important source of support during the illness [ 17 ]. Asgari et al. also obtained the two concepts of family unification and empathy and responsible accountability of nurses [ 18 ], which is in line with the results of this research.

Therefore, it can be concluded that although hemodialysis patients are exposed to mental stressors, empathy and psychological support can help them with these stressors. Empathy from different sources such as family and health care staff can reduce the physical and psychological problems of these patients, thereby helping the patients to cope with the illness more easily, keep away from isolation and gain more vitality and energy.

Accompaniment in meeting daily needs of the patients was another extracted main theme and the participants emphasized that accompanying them with daily activities and providing appropriate nutrition is a concept of care. These patients usually suffer from pain, energy shortages, insomnia and heart condition, and limitation in their physical activity disrupts their physical functioning in such a way that they have difficulty in doing their daily activities [ 1 ]. Uremia causes irritability, loss of appetite, insomnia, fatigue, memory loss, impaired judgment and poor concentration and, consequently, these patients sometimes need help in doing their simplest daily tasks [ 19 , 20 ].

Another need of these patients is the provision of food by the family and based on the prescribed diet. Most of the participants stated that, because of fatigue and decreased energy, they are not able to prepare the recommended food, do not have the incentive to follow the diet, and need the support of their family. Haririan et al. showed that supporting the patients increases their compliance with therapeutic regimen, especially food regimen, thereby improving the quality of life in them [ 21 ]. In a qualitative research investigating the barriers of adherence to therapeutic regimen in the patients with type 2 diabetes, the participants have stated that one of the factors impeding the compliance with therapeutic regimen has been inadequate family support [ 7 ].

From the statements of the participants and the mentioned studies it can be concluded that accompaniment in meeting the daily needs of the patients is a very important factor that should be considered in designing a care plan for these patients.

From the viewpoint of the participants, support through increasing the society’s understanding of the patients’ condition, providing appropriate jobs and financing were other care-related concepts. The type of the support and the patient’s perception of it contribute to its effectiveness, so that the participants stated that they dislike pity and expect others to understand their conditions, and believed that effort to achieve this goal is related to the concept of care. Siegert et al. found that dialysis exerts a pressure on the patients and their family, but the reaction of others can have a significant impact on their mental status [ 22 ]. Therefore, it seems that changing society’s attitudes and understanding towards these patients would help to support these patients instead of pity them.

The necessity of employment and financing were two other sub-themes extracted from the statements of the participants and emphasized by most of them. As these patients spend a considerable amount of time doing dialysis and medical care and are often not in a good condition, they often encounter many limitations with regard to their employment, lose their jobs and have many economic problems. Accordingly, they expect the government and the association for the support of kidney patients to provide the ground for their employment and believe that such a support is one of the concepts of care. Rafiee and Rambod also showed that many hemodialysis patients had lost their jobs and experienced many economic and social problems and were unable to provide some of their own and their family needs [ 23 ]. However, it should be noted that financial problem of the patients is not specific to our country, as Hui-Dan et al. also found that most hemodialysis patients have a lot of financial problems [ 24 ].

The support of social organs for patients, especially economic support, reduces the problems of these patients and plays an important role in tolerating the disease. Most of the participants of this study were satisfied with the support of social organizations, but did not consider it enough and expected more support, especially more financial support [ 9 ]. Therefore, designing a social support program, including economic support for these patients seems to be essential.

High-quality dialysis was another extracted main theme and, in this regard, a meticulous care during dialysis and using a well-functioning dialysis machine were emphasized by the participants. They stated that care during dialysis, including minute adjustment of the dialysis machine, blood pressure control, precise weight control and having sufficient skill in dialysis, is of particular importance. Kaba et al. wrote that patients undergoing hemodialysis always suffer an anxiety caused by possible problems and the likelihood of death during dialysis and, hence, dialysis nurses should have the sufficient knowledge and skill to prevent such problems [ 4 ].

The nurse should have enough information about the patient and the dialysis machine in order to implement a safe and high-quality dialysis program [ 25 ]. Therefore, meticulous care during dialysis was considered by the participants to be essential. The participants complained about broken machines, their frequent alarms and their inability to lose weight and believed that the existence of unbroken dialysis machines is the proof of a high-quality dialysis. Dialysis machine is an integral part of treatment for these patients and the proper function of the machine can directly affect the outcome of the treatment and complications of the dialysis [ 26 ]. Thus, according to the participants, high-quality dialysis was one of the concepts of care that should be considered in the design of a care program for these patients.

Although qualitative research gives us a deep understanding of the phenomenon, because of the expansion of different topics, one cannot get all the dimensions of a topic in interviews with a limited number of individuals. Accordingly, revealing new themes is likely only through conducting more interviews with a diverse sample of participants not captured in this study. Therefore, although data saturation in this research was reached, additional participants in future studies may address more dimensions of the concept of care.

According the findings, we can answer the research question that “what is the lived experience of hemodialysis patients with the concept of care?” From the viewpoint of the patients, empathy, accompaniment in meeting daily needs, social support and concern, and high-quality dialysis constitute the concept of care. One of the unique results of the present study, compared with other similar ones, was the emphasis of the participants on the mental aspects of care. Accordingly, these aspects have to be considered in the care plans designed by the healthcare team for these patients.

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Acknowledgements

The current article resulted from the research project No. 293333 which was approved by the Isfahan Kidney Disease Research Center. Hence, it is incumbent upon us to express our gratitude for the genuine cooperation of the chairman and the members of this center and all those who helped us in this research, especially the participants.

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Critical Care Nursing Department, Faculty of Nursing and Midwifery, Isfahan University of Medical Science, Isfahan, Iran

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Hojatollah Yousefi

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Mrs. NS contributed in interview, analyzing, and interpreting the patient data and writing the manuscript. Dr. HY contributed in Data interpretation, manuscript writing and editing, and all authors have read and approve the final version of manuscript.

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Shahgholian, N., Yousefi, H. The lived experiences of patients undergoing hemodialysis with the concept of care: a phenomenological study. BMC Nephrol 19 , 338 (2018). https://doi.org/10.1186/s12882-018-1138-4

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Efficacy of nurse-led interventions on dialysis-related diet and fluid non-adherence and morbidities: protocol for a randomized controlled trial

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Hemodialysis is the most sought after modality of treatment in patients with end stage renal disease. The success of hemodialysis depends on patient’s adherence to diet and fluid restrictions to a great extent. The study aimed to examine the efficacy of nurse-led-interventions on dialysis related diet and fluid non-adherence and morbidities.

The study will adopt quantitative approach and the design will be a parallel arm block randomized controlled trial with 6 th & 10 th week follow-ups. Hemodialysis patients, who fulfill inclusion and exclusion criteria, will be enrolled for the study as study participants. Baseline data will be collected after screening the participants and they will be randomized into an experimental or control group. The experimental group will receive nurse led interventions and the control group receives the standardized care. Participants will be randomized using sequentially numbered opaque sealed envelopes (SNOSE) according to computer-generated random order. Block randomization using randomly varying block sizes ensure equal numbers of subjects in each group with 1:1 allocation ratio. Primary outcomes are self-reported adherence and biochemical markers of adherence. An independent assessor will measure the endpoints at baseline and at 6 th and 10 th week after the intervention.

Conclusions

This theory based Nurse led intervention trial designed based on vigorous review of previous research emphasizing the importance of nurse specific interventions to empower patients and enable them to be adherent with their treatment regimen. Inclusion of both subjective and objective measures of adherence will enhance the vigor of this trial and allows evaluating the extensive impact on the intervention including both hard end points as well as patient reported outcomes. If the nurse led intervention is found to be effective, this cost effective potential program can be implemented in all dialysis centers by giving dialysis specific and psychologically imbued training to all dialysis nurses of our country that will really cater the needs of dialysis patients.

Trial Registration Number

CTRI/2019/06/019894

INTRODUCTION

Chronic Kidney Disease (CKD) has become a mammoth public health concern, and its surge tends to have an uninterrupted triumph. 1 Approximately 10% of the world population is victim of this enormous ailment. Global Burden of Disease Study- 2015, has reported renal disease was the 12 th most common cause of mortality, and globally responsible for 1.1 million deaths. 1 , 2 Prevalence of CKD in India is estimated as 13–15.04% with stage 1, 2 and 3 as 6.62%, 5.40% and 3.02% respectively. 3

Hemodialysis (HD) is a decisively essential management modality in patients with end stage renal disease (ESRD) that extends the life expectancy and enhances the quality of life (QOL). 4 One of the prevalence studies among HD patients estimated more than 50% are non-adherent in some ways within the first month and upwards of 70% of clients fail to successfully control their fluid ingestion. 5 Such alarming rates are a matter of concern because even irregular occasion of serious non-adherence can result in lethal complications. Worldwide numerous interventions and therapies had been developed to enhance compliance to HD regimen and QOL. 5–10

Griva et al pointed out the benefits of a self management intervention (SMI) on HD patients through their randomized controlled trial (RCT) . This study recruited 176 adults undergoing HD at least for 6 months and they were randomized to self management or standard care groups. In this multicentre parallel arm block RCT of a four session group SMI for HD delivered by health care professionals compared to standard care. The SMI was revealed to be effective in terms of adherence and QOL. 6

Chen CC et al through their meta-analysis emphasized that QOL of CKD patients improved through nurse led disease management program. They had comprised eight studies and 1520 patients, with 766 clients allocated to the nurse-led disease management schedule. It was observed nurse-led disease management significantly magnified the QOL in terms of general health perception, symptoms, pain, energy/fatigue, staff encouragement, sleep, overall health and psychological component summary when determined 6 weeks after the commencement of intervention. 5 Nursing intervention consists of the appliance of behavioral, educational, cognitive and dietary techniques that has been depicted to had positive effects on the emotional and physical health of patients with ESRD. 5–10

Ahrari et al in their study on ESRD patients in Iran mentioned that non-adherence to diet and fluid control is a primary reason for treatment letdown and deprived outcomes. 11 However, predictors that impede with the patients’ capability to pursue their dietary control remains unidentified. Through their study about Jordanian HD patients, Khalil et al suggested that recognition of predictors that may aggravate diet and fluid non-adherence may contribute to get favorable therapeutic outcomes via explicitly developed interventions. 12 , 13

Beerappa and Chandrababu in their prevalence study recommended the need of a well framed RCT on fluid and diet adherence in order to develop useful interventions for evidence based practice. 14 A meta-analysis by Wang et al showed that nursing interventions improved patient’s adherence to HD, and the mean effect was found to be 15% in total. 10 Hence, evidence based therapeutic nursing interventions, that are cost effective and readily accessible are vital for facilitating adherence behavior. 10

Dietary and fluid adherences are quintessential components in the management of ESRD patients. 6 Non-adherence to diet and fluids restriction may result in increased morbidity and mortality because of the accumulation of toxic fluids and end products of metabolism in the blood. 5 These literatures suggest that such existing psychosocial interventions facilitate adherence and enhance self-care management among HD patients. However majority of such studies are methodologically underpowered, intervention protocols are poorly defined and developed, very short follow up duration and marked with lack of simultaneous inculcation of both psychological and clinical outcomes. 12 , 14 Other criticism in reviews are the lack of detailed description of the required training, inadequate theoretical or conceptual support of these intervention that might have ultimately degrade fidelity of the existing intervention in many studies. 7–10

Although certain studies pointed out different psychological interventions to fill the gap in the knowledge, unfortunately a scientific conscience is lacking. 5 , 7–10 This vivid gap in the evidences provoked the researcher to initiate a work plan to solve this unresolved dilemma. The proposed RCT will tackle the fragility of previous counterpart studies by framing a well defined methodology, recruiting sufficiently large and representative HD patients, the development of well designed, evidence based and theory driven intervention and the inclusion of validated and reliable measurement tools to ascertain adherence and health related outcomes through subjective as well as objective methods. Hence this trial will probably endow with much needed data on the efficacy of nurse led interventions with respect to adherence and other health related outcomes that can confer evidence based clinical practice and health care services.

The study aimed to examine the efficacy of nurse-led-interventions on dialysis related diet and fluid non-adherence and morbidities

H 1 : Dialysis patients participating in nurse led intervention sessions will be more adherent to dietary and fluid restrictions compared with patients not in the intervention group

H 2 : Dialysis patients receiving nurse led interventions will have less morbidities compared with patients not in the intervention group

Approach and design

The study will adopt quantitative approach and the design will be a parallel arm block randomized controlled trial with 6- and 10-weeks follow-ups. The study design is guided by the CONSORT statement ( Figure 1 ).

Study population & participants

CKD patients who are registered and receiving maintenance hemodialysis from selected hospital of Kerala, India will be study population. CKD patients, receiving hemodialysis, who fulfill inclusion and exclusion criteria, will be enrolled for the study. Baseline data will be collected after screening the participants and they will be randomized into an experimental or control group. The experimental group will receive nurse led interventions and the control group receives the standardized care. It will be voluntary for the patients to participate in the study.

Inclusion criteria will be adopted are patients:

To have a medical diagnosis of CKD and undergoing maintenance hemodialysis

To be aged above 20 years

Receiving hemodialysis at least for last three consecutive months

To have a mobile connection

To be able to read and understand Malayalam/Tamil/English

• The exclusion criteria will be:

Not willing to participate in intervention

A diagnosis of functional psychosis or organic brain disorder

Impaired cognition

Major visual or hearing impairments, or other sensory or motor impairments that may prohibit completion of the scheduled assessments

Limited life expectancy

Nurse led interventions (NLI)

This intervention is basically a process of empowering patients to make choices and lifestyle changes in line with treatment recommendations through the use of problem solving, goal setting and feedback. It emphasizes patients’ central role and responsibility in managing their illness. The program offers the potential for people to learn about their condition and treatment in a psychologically motivating and confidence enhancing structure.

Sessions will be facilitated by the researcher himself and the intervention components will include problem solving, overcoming barriers, challenging beliefs, conducting brainstorming sessions, goal setting, and reinforcement. Targeted behaviors will include fluid control and diet restriction. This nurse led interventions consist of nurse led brief advice, brief motivational intervention, telephonic booster intervention and daily morning reminder SMS.

Nurse led Brief Advice (NBA): Brief advice to dietary and fluid restriction includes information regarding guidelines for diet and fluid management in dialysis, its importance and consequences of non-adherence. Brief advice will be lasted for 20 minutes.

Brief Motivational Intervention (BMI): BMI is based on motivational interviewing, which will enhance the transformation of non-adherent behavior in to adherent behavior. The primary components consist of acknowledging the patient’s autonomy regarding their adherence behavior; providing personalized feedback based on preliminary assessment, encouraging patients to explore the pros and cons of dietary and fluid restriction; assessing importance, confidence and readiness to be adherent; supporting patients’ self-efficacy; and reinforcing efforts or intentions to make positive changes in behavior. Brief motivational interventions lasted an average of 20 minutes.

Telephonic Booster Intervention (TBI) & Daily Morning Reminder SMS (R-SMS): Telephonic booster intervention will be administered on the third post intervention day for about 10 minutes. During which the researcher will further identify the existing problems of patient based on feedback information. The researcher will utilize the situation to motivate the client to be adherent with the guidelines focusing on his/her strength and weakness with a purpose to ensure self efficacy and a change in behavior. From the second day of intervention, a daily reminder SMS will be sending to the participant’s mobile number until the 10 th week.

Outcome measures and data collection

Primary outcomes are self reported adherence and biological & biochemical measures of adherence (inter-dialytic weight gain, serum potassium, phosphorus, urea, creatinine and blood pressure). Secondary outcomes are anxiety and depression, quality of life, self efficacy and dialysis and CKD related morbidities. These endpoints will be ascertained at baseline and at 6 th and 10 th week post-intervention by an independent assessor, who is not aware about the allocation.

The senior nurse in the dialysis center, will screen patients for eligibility and give a list of eligible patients. After baseline assessment, each participant will be randomized to either a control or intervention group. Three separate helpers will be there for generating sequence, enrollment and for allocation. This concealed randomization ensures both the researcher and participants are not aware of whether the next eligible participant will be allocated in to control or intervention arms. This will be masked until the time when participants are ready to receive intervention. Intervention will be administered by the researcher himself. Structured Interview technique and self reporting will be employed throughout the data collection period. Data will be collected during the hemodialysis session. Follow up measurements of outcomes will be assessed at 6 th and 10 th week in both groups.

Sampling technique and size

Purposive sampling technique will be adopted for the study. Eligible CKD patients will be sequentially recruited to the study. A sample size of 90 was estimated with the help of Openepi software 15 with 80% power and 5% significance level to achieve the maximum effect at 80%. After estimating 20% attrition rate, the sample size is re-estimated into 110 (55 in each group).

Randomization and blinding

Following baseline measurement, each participant will be randomized to either a control or intervention group. Participants will be randomized by means of sequentially numbered opaque sealed envelopes (SNOSE) prepared according to a computer-generated random allocation order. Block randomization using randomly varying block sizes guarantee equal numbers of participants in each group with 1:1 allocation ratio. The blinding of participants and investigator is not possible here, however, the outcomes will be ascertained by independent observer (trained nurse) who will be unaware of the allocation and treatment arms of participants.

Ethical considerations/clearance

Institutional ethical committee permission has been taken. A study information sheet will be given to participants and the researcher will further verbally explain the study protocol and prerequisites in a simple language that patient can readily understand. Participation in the study will be of purely voluntary basis and will inform that they can withdraw at any time as they wish. A written informed consent shall be obtained from the participants before enrolling them in to the trial.

Plan for data analysis

After the data collection, descriptive and inferential statistics will be used for the data analysis. A statistical significance of 0.05 ( P <0.05) will be adopted throughout the study.

Patient empowerment is the corner stone of the management of any chronic diseases. In such cases, adaptation with the treatment regimen and certain life style modifications are mandatory. As a well-trained health care professional nurses have tremendous role in the empowerment of such patients. Nursing care is always focused on multidimensional aspects of human being; they can influence the patient to ensure the necessary modifications in their daily life.

This theory based Nurse led intervention trial designed based on vigorous review of previous research emphasizing the importance of nurse specific interventions to empower patients and enable them to be adherent with their treatment regimen. Inclusion of both subjective and objective variables of adherence will enhance the strength of this trial and allows us to assess the broader impact on the intervention including both hard end points as well as patient reported outcomes. If the nurse led intervention is found to be effective, this cost effective potential program can be implemented in all dialysis centers by giving dialysis specific and psychologically imbued training to all dialysis nurses of our country that will really cater the needs of dialysis patients. The design of this trial will probably tackle limitations of prior studies by recruiting adequately sized and representative sample to determine clinically significant changes in biochemical markers, a theory based intervention protocol and careful measurement of both subjective and clinical variables at different follow up periods. Keenly designed, this trial will hopefully contribute to the wisdom of research, clinical practice and ultimately for the benefit of hemodialysis patients.

CONCLUSIONS

This study has started with a question, whether nurse lead interventions improve adherence to dietary and fluid restrictions and other health related outcomes among patients with chronic kidney disease? This theory based interventions and well driven trial will definitely detect a solid solution for this research question.

Acknowledgements

The authors would like to acknowledge Dr. Manju Thampi (Senior Nephrologist, NIMS), Dr. Manju Dhandapani (Senior faculty, PGIMER Chandigarh), Dr. Asha Sharma (Former INC Secretary), Mr. Shine Stephen (Faculty AIIMS) for their continuous support throughout the planning phase of this protocol.

This study had no financial support from any individuals or organizations.

Conflict of interest

The authors completed the Unified Competing Interest form at http://www.icmje.org/coi_disclosure.pdf (available upon request from the corresponding author) and declare no conflicts of interest.

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Top 100 cited articles on hemodialysis

A bibliometric analysis.

Editor(s): Attia., Doaa

Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea.

∗Correspondence: Bong Soo Park, Department of Internal Medicine, Inje University Haeundae Paik Hospital, 875 Haeun-daero, Haeundaegu, Busan 48108, Korea (e-mail: [email protected] ).

Abbreviations: ESRD = end-stage renal disease, HD = hemodialysis.

How to cite this article: Lee YJ, Heo CM, Park S, Kim YW, Park JH, Kim IH, Ko J, Park BS. Top 100 cited articles on hemodialysis: a bibliometric analysis. Medicine . 2021;100:38(e27237).

YJL and CMH contributed equally to this work.

The authors have no conflicts of interest to disclose.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0

Introduction: 

This study was conducted to better understand hemodialysis by reviewing the most-cited articles related to it.

Methods: 

We searched articles on the Web of Science and selected the 100 most frequently cited articles. Subsequently, we reviewed these articles and identified their characteristics.

Results: 

The 100 most frequently cited articles were published in 21 journals. The majority of these papers were published in the following journals: Kidney International (26 articles), New England Journal of Medicine (18 articles), Journal of the American Society of Nephrology (14 articles), and the American Journal of Kidney Disease (13 articles). The 100 most-cited articles were published in 25 countries. The United States of America was the country with the highest number of publications (65 articles). The University of Michigan was the institution with the highest number of articles (14 articles). FK Port was the author with the largest number of publications (13 articles).

Conclusions: 

This is the first study in the field of nephrology that provides a list of the 100 most-cited articles on hemodialysis. Through this study, clinicians will be able to recognize major academic interests and research trends in hemodialysis.

1 Introduction

A progressive stage of chronic kidney disease with a glomerular filtration rate of less than 15 mL/min/1.73 m 2 is defined as end-stage renal disease (ESRD). ESRD is one of major global health problems. Its prevalence is gradually increasing worldwide and in Korea. [1,2] ESRD patients often experience various complications including multiorgan dysfunction. In ESRD, hemodialysis (HD) and peritoneal dialysis are mainly used for renal replacement therapy. As both therapies have their advantages and disadvantages, the choice of the treatment method can be decided by the physical condition, patient's preference, or comorbidities. The number of patients requiring HD continues to increase annually. According to research by the National Health Insurance Service on medical aid, the number of HD patients increased by 31.9% from 44,136 in 2006 to 58,232 patients in 2010. [3,4]

The Science Citation Index was explained by 1964 at the Institute for Scientific Information. This was used to confirm that the academic contribution of the journal was high. It was also used to collect citation information and build indexes for database screening of scientific articles. Science Citation Index has become one of the most widely and frequently used databases for searching journals and assessing research outcomes. In the area of science, by increasing the number of articles, the availability of these articles in the form of compact discs or books was limited. This has resulted in a larger web version, known as the Web of Science: Science Citation Index Expanded.

The number of citations received by an article reflects the level of interest of the academic community in that particular topic. Therefore, a large number of citations indicate the significant impact of this article in the scientific community. The most frequently cited articles provide interesting insights into the process by which articles, subjects, and authors influence the field of research over time. By reviewing the most-cited articles, it can provide information on key areas of interest and avenues of research that have shown substantial growth in a specific field. Several researches have already analyzed the most frequently cited papers in several fields such as emergency medicine, general surgery, orthopedic surgery, plastic surgery, anesthesiology, obstetrics and gynecology, dermatology, critical-care medicine, and headache disorders. [5–13] However, no research has previously analyzed the 100 most-cited articles on HD.

This study presents the most cited articles related to HD and aims to broaden the understanding of HD through it.

We conducted an analysis of the citation-related HD. The study was performed as follows: First, we only searched for HD-related articles, except for peritoneal dialysis-related articles. We searched the Web of Science ( https://apps.webofknowledge.com ) by restricting the document type to reviews and journal articles. The publication period was from 1969 to 2019. Articles meeting these criteria were sorted by the number of citations they had received.

Second, according to citation frequency, we selected 100 articles on HD. We then reviewed the contents of each article and classified them by the number of citations, year of publication, publishing journal, published country, authorship, and topic categories. The topic categories were organized as pathophysiology, epidemiology, survival and mortality, mineral metabolism, and vascular calcification. The first author was used as the criterion when there was more than 1 author. Recommendations were excluded from the study. No statistical techniques were used in this study. The data are presented as frequencies only. Since this study is an analysis of data from online databases and the privacy of patients will not be disclosed, so patients‘ informed consent and ethical approval are all not required.

A total of 8941 HD-related articles were identified and analyzed. We chose the 100 most frequently cited papers and arranged them in descending order by the number of citations ( Table 1 ). The most frequently cited paper was cited 1802 times, and the paper with the least number of citations was cited 322 times. Most of the papers (80 articles) received more than 360 citations.

The 100 most-cited articles were published in 21 journals. Of the 21 journals, the one with the highest number of the most cited articles was Kidney International (26 articles), followed by New England Journal of Medicine (18 articles), Journal of the American Society of Nephrology (14 articles), and the American Journal of Kidney Disease (13 articles). Over half of these articles were published in these 4 journals (58 articles) ( Table 2 ).

These studies were published in 25 countries. The United States of America had the highest number of publications (65 articles), followed by France (20 articles), Japan (14 articles), Germany (10 articles), and Canada (8 articles) ( Table 3 ).

The decades during which these articles were published are shown in Figure 1 . Of all the articles, 55 were published in the past 2 decades. The earliest published article was published in 1966, while the most recently published article was published in 2013. More than 60 of the 100 most cited articles were provided by 17 institutions ( Table 4 ). In articles with multiple authors, counting was based on the institution of the first author. The University of Michigan (14 articles) and the University of Michigan System (14 articles) were the institutions that published the highest number of articles, followed by the Assistance Publique Hopitaux Paris (12 articles) and the University of California system (12 articles).

The top authors who have published more than 4 articles on HD are listed in Table 5 . FK Port was the author who published the most number of articles (13 articles).

4 Discussion

In this article, we searched and reviewed the 100 most-cited articles on HD. These articles provided advanced insights on scientific perspectives and progress in the field of HD.

The most-cited article was published by the Journal of the American Society of Nephrology in 2004 and was written by the Block. [14] To identify associations between mineral metabolism disorders (hypercalcemia, hyperphosphatemia, and secondary hyperparathyroidism), mortality, and morbidity in HD patients, a nationally representative database of >40,000 HD patients was analyzed. This study showed strong associations between higher concentrations of serum calcium and phosphorus and higher mortality. They also found associations between hyperphosphatemia and hyperparathyroidism and cardiovascular, fracture, and all-cause hospitalization. These results support the hypothesis that mineral metabolism disorders are associated with the risk of cardiovascular disease in ESRD patients.

The second most cited article was published by the American Journal of Kidney Disease , entitled “Association of serum phosphorus and Ca × PO 4 product with mortality risk in chronic HD patients: A national study.” [15] The goal of this study was to estimate the level to which serum phosphorus is maintained in 2 large national, random samples of patients who have been receiving HD for at least 1 year. Ca × PO 4 product levels above 72 mg 2 /dL 2 were observed in 20% of the patients and were associated with a higher relative risk of death compared with those with a Ca × PO 4 product between 42 and 52 mg 2 /dL 2 . These results support that intensive control of hyperphosphatemia can increase the survival rate of patients.

The most frequent topic discussed in these articles was cardiovascular mortality in hemodialysis patients (22 articles). The most cited article about cardiovascular mortality in HD patients was authored by Lindner in 1974 and published by the New England Journal of Medicine . [16] This study reviewed mortality and morbidity due to cardiovascular complications in long-term HD patients in Seattle. The results showed that the incidence of arteriosclerotic complications was several times higher in this group than in the normal and hypertensive groups of comparable age, and was similar to the rate of cardiovascular complications found in patients with type 2 hyperlipoproteinemia. These outcomes indicate that increased atherosclerosis is a major risk for patients on long-term maintenance HD. The second most frequently discussed topic was chronic kidney disease-mineral and bone disorder in HD patients (15 articles). The articles about this topic provided information about laboratory changes in mineral metabolism during HD and mortality risks in chronic HD patients.

We also found some interesting trends among the subjects of the articles owing to the fact that they kept on changing from decade to decade. First, pathophysiology was the most frequently covered subject. The main key words related to this topic are: uremia, electrolyte, mineral metabolism. This was similar to the results of analyses performed in other fields. [4,5,7,12] Other subjects often covered in articles were treatment and basic research. Second, an increasing number of articles were published as time passed from the 1990s to the 2010s. From 2000 to 2009, 53 of the 100 most-cited articles were published. Papers related to Chronic Kidney Disease-Mineral and Bone Disorder were more common before the 2000s, whereas papers on more diverse topics were published after the 2000s. Articles on the most common topic, cardiovascular mortality in HD patients, were published mainly after the 2000s. The main key words related to this topic are: atherosclerosis, vascular calcification. This trend is thought to be because of the higher concern regarding long-term complications, mortality, and morbidity in patients receiving maintenance HD.

Sixty-five articles were published in the United States, while 20 articles were published in France. In other areas where similar studies were conducted, the highest number of papers was published in the United States. [4–7,9–12] Kidney International published the highest number of the most cited articles (26 articles), followed by the New England Journal of Medicine (18 articles). American institutions have made significant contributions to the advancement of HD research. This is because the American scientific community can conduct research with enormous financial resources. Moreover, American writers prefer to publish their research in easily accessible American journals and usually cite papers written in English. [17]

We found that none of the 100 most cited papers originated in Africa. This may be due to the difficulties in accessing information, conducting and publishing research, and the language barrier experienced by researchers in Africa.

Our study has some inherent limitations. This research was conducted because of the controversy regarding the value of citations. The number of citations does not reflect whether the study was referenced in a positive or negative way. [18] The papers cited most frequently may not necessarily be the most important and meaningful one. [19] Certain types of articles, such as meta-analyses, systematic reviews, and guidelines tend to be cited more than others. [20] In addition, older papers tend to be cited more frequently. However, evaluating the number of citations is a better way to assess the advantages of a paper. Analysis about citation rate is able to prove the advancement in a particular field of expert knowledge and give a retrospective aspect of scientific development. [21]

5 Conclusions

This is the first study in the field of nephrology to provide a list of the 100 most-cited articles on HD. This study provides major academic interest and research trends related to HD.

Author contributions

Conceptualization: Sihyung Park, Bong Soo Park.

Data curation: Yoo Jin Lee, Sihyung Park.

Formal analysis: Junghae Ko.

Investigation: Jin Han Park, Il Hwan Kim, Junghae Ko.

Project administration: Yang Wook Kim.

Supervision: Yang Wook Kim, Bong Soo Park.

Validation: Jin Han Park, Il Hwan Kim.

Visualization: Jin Han Park, Il Hwan Kim.

Writing – original draft: Chang Min Heo.

Writing – review & editing: Chang Min Heo, Yoo Jin Lee, Bong Soo Park.

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Article Details

Main article content, integrated dialysis nursing intervention for ameliorating fatigue in hemodialysis patients, yogalakshmi s., sasikala d., santosh varughese, vasanthakumari sundararajan.

BACKGROUND: Fatigue is a pervasive and debilitating symptom among hemodialysis patients, severely impacting their quality of life and ability to participate in social activities. Dialysis nurses are pivotal in alleviating these effects through physical exercise. This study aims to evaluate the effectiveness of an integrated dialysis nursing intervention in reducing fatigue among hemodialysis patients.

METHODS: A quasi-experimental time series design was employed, involving 295 hemodialysis patients (148 in the experimental group and 147 in the control group) selected through consecutive sampling from two dialysis units in Chennai. Baseline fatigue was assessed in both groups. The experimental group received the integrated dialysis nursing intervention, including 15-minute sessions of aerobic exercises three times a week for eight weeks. The control group continued with routine care. Fatigue levels were reassessed at the end of the fourth and eighth weeks. Data were analyzed using SPSS version 20.

RESULTS: The study revealed a significant reduction in fatigue scores in the experimental group compared to the control group, with p < 0.001 in post-test I and II. The experimental group showed greater improvement than the control group, with p < 0.05.

Conclusions: The integrated dialysis nursing intervention significantly reduced fatigue in hemodialysis patients. Incorporating this approach into routine intradialytic care can enhance fatigue management and improve patients' quality of life.

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Nursing researcher to study e-cigarette cessation in adolescents

By CHARLES ANZALONE

Published September 27, 2024

School of Nursing researcher Eunhee Park has received a $745,000 grant from the National Cancer Institute to develop a digital system to prevent e-cigarette use among adolescents.

Park’s work centers on developing, implementing and disseminating effective interventions that reduce the harms of risky behaviors, particularly focusing on smoking and substance use prevention among young people with low SES.

Her latest grant — AI-Enhanced App-based Intervention for Adolescent E-Cigarette Cessation, for which she serves as principal investigator — aims to create a scalable, electronic cigarette (e-cigarette) use cessation intervention using a smartphone application.

The project will address adolescent e-cigarette use, which Park, an assistant professor of nursing, says is an emerging public health problem.

In 2022, 14.1% of high school students and 3.3% of middle school students used e-cigarettes, according to her proposal, even though e-cigarette use is known to be “harmful to adolescent health, resulting in nicotine-related symptoms of addiction and various other health issues (e.g., depressive symptoms), and is associated with use of other addictive substances.”

Thus, Park says, effective and sustainable interventions to address adolescent e-cigarette use are urgently needed.

Park’s study aims to create a targeted e-cigarette use cessation intervention using a smartphone app, which can be delivered to a large pool of adolescents.

Timely messages will be sent in response to users’ urges to use e-cigarettes based on self-report in real time through the smartphone app. In addition, AI will be able to answer the users’ questions using an automated chatbot.

“We will examine the usability of the intervention based on user experiences of functions, interface, content, frequency of app use and minutes of app use,” Park says. “Then, we will pilot-test the intervention for summative evaluation using a quasi-randomized controlled study using a delayed intervention design.

“Over the long term, the findings of this study will contribute useful information for those testing the effectiveness of smartphone app-based interventions for adolescent e-cigarette use cessation on a large scale.”

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James Coleman Battista

Associate Professor of Political Science

Expertise: national, state and legislative politics  

Phone:  716-645-8438

Email: [email protected]

Marc Halfon

Professor of Biochemistry

Expertise: genetics; gene expression; gene drive; genome editing; mosquito genome; cell growth, differentiation and development

Phone:  716-829-3126

Email: [email protected]

Michael J. Poulin

Associate Professor of Psychology

Expertise: empathy, human generosity, stress, caregiving

Phone: 716-645-0518

Email: [email protected]

Joan Linder

Professor of Art

Expertise:  drawing, consumption and mass production, mundane objects, modern life, Love Canal and other toxic sites, environmental art, feminist art, power, public art

Phone:  716-645-0539

Email:  [email protected]

Susan Green

Co-director of the Institute on Trauma and Trauma-Informed Care

Expertise: trauma, trauma-informed care in organizations and service delivery systems

Phone: 716-645-1249

Email: [email protected]

Amanda Nickerson

Director of the Alberti Center for Bullying Abuse Prevention

Expertise: school violence, bullying prevention and intervention, parent and peer relationships, assessment and treatment of emotional and behavioral disorders

Phone: 716-645-1532

Email: [email protected]

Mark Swihart

SUNY Distinguished Professor and Chair of Chemical and Biological Engineering

Expertise: nanotechnology, materials science, chemistry of materials, aerosol science

Phone: 716-645-1181

Email: [email protected]

Stephanie A. Poindexter

Assistant Professor of Anthropology

Expertise: biological anthropology, primate evolution, primate conservation

Phone:  716-645-0427

Email: [email protected]

Surajit Sen

Professor of Physics

Expertise: wave behavior, granular systems, quasi-equilibrium, nonequilibrium and chaotic phenomena, collisions, shock mitigation, sociophysics

Phone:  716-645-6151, 716-907-4961

Email: [email protected]

Annette Semanchin Jones

Associate Professor and Director, PhD in Social Welfare program

Expertise: child welfare, foster care, child protection services

Phone:  716-645-1862

Email: [email protected]

Annette Wysocki

Dean of the School of Nursing

Expertise: wound care, delayed healing in chronic wounds, federal funding of nursing programs, media representation of nurses, ethical guidelines.

Phone:  716-829-3308

Email:  [email protected]

Assistant Professor of Sociology, and of Global Gender and Sexuality Studies

Expertise:  labor, work, gender and political economy, especially in China; labor and feminist movements in China and in a global context

Phone:  716-645-2417

Email:  [email protected]

Elizabeth Mazzolini

Associate Professor of English

Expertise: Mountaineering deaths, climbing technology, consumerism, material culture, garbage, culture of waste

Phone:  716-645-0691

Email: [email protected]

Ifeoma Nwogu

Associate Professor of Computer Science and Engineering

Expertise: artificial intelligence, including machine learning and human behavior; computer vision and facial expressions, and gestures and sign languages

Phone:  716-645-1588

Email:  [email protected]

Associate Professor of Accounting and Law

Expertise: corporate voluntary disclosures; accounting fraud; environmental, social and governance (ESG) accounting; mergers and acquisitions (consolidation) accounting; executive and employee turnover; accounting-marketing interface

Contact:  Inho Suk can be reached most quickly through Jackie Ghosen in the School of Management Communications Office at 716-645-2833 or [email protected] .

Jeffrey M. Lackner, PsyD

Chief of the Division of Behavioral Medicine

Expertise: irritable bowel syndrome (IBS), psychosocial aspects of chronic pain disorders, behavioral medicine, brain-gut interactions, impact of chronic disease on quality of life, chronic care management

Phone:  716-898-5671

Email: [email protected]

James M. Chen

Associate Professor of Mechanical and Aerospace Engineering

Expertise:  materials science, turbulence, energy harvesting, hypersonic/supersonic vehicles, aerodynamics, nonequilibrium phenomena, high-performance computing

Phone:  716-645-3163

Email: [email protected]

Panayotis (Peter) K. Thanos

Senior Research Scientist of Pharmacology and Toxicology

Expertise:  ADHD treatment, addiction; brain imaging; alcohol and drug abuse, obesity, binge eating disorder, bariatric surgery, prenatal nicotine use, prenatal cannabis

Phone:  716-881-7520

Email:  [email protected]

Shermali Gunawardena

Associate Professor of Biological Sciences

Expertise:  neurons, axonal transport, biology of neurodegenerative diseases

Phone:  716-645-4915

Email:  [email protected]

Riana R. Pryor

Assistant Professor of Exercise and Nutrition Sciences

Expertise:  heat and exercise; heat illness, including heat stroke; hydration; high school sports and athlete safety; occupational safety; exercise physiology

Phone:  716-829-5456

Email:  [email protected]

Howard Lasker

Professor Emeritus of Environment and Sustainability

Expertise: coral reefs; coral bleaching; climate change and oceans

Phone:  716-645-4870

Email: [email protected]

Kristin Stapleton

Professor and Chair of History

Expertise: modern China; U.S.-China relations; Chinese cities; history of the family, socialism and humor in China

Phone:  716-645-5645

Email: [email protected]

David Herzberg

Professor of History

Expertise:  opioid epidemic; history of prescription drugs, street drugs and other psychoactive substances; drug policy and drug wars; drugs and popular culture; addiction; drugs and social inequalities of race and gender  Phone:  716-645-8416

Email: [email protected]

John A. Sellick Jr.

Professor of Medicine

Expertise: infectious disease, outbreaks and pandemics, vaccinations, bioterrorism planning, flu, Ebola

Phone:  716-862-8758

Email: [email protected]

Ia Iashvili

Expertise: Higgs boson search, particle detectors, search for supersymmetric particles

Phone: 716-645-6611

Email: [email protected]

Anne B. Curtis

SUNY Distinquished Professor

Expertise: heart health, heart rhythm abnormalities, atrial fibrillation, cardiac devices, pacemakers, implantable cardiac defibrillators, cardiac problems in winter

Phone: 716-859-4828

Email: [email protected]

Erin Hatton

Professor of Sociology

Expertise: labor movements, gig economy, job security, coerced labor, pay for college athletes, minimum wage, workfare

Phone:  716-645-8476

Email: [email protected]

Nichol Castro

Assistant Professor of Communicative Disorders and Sciences

Expertise:  speech, language and memory; word retrieval; anomia, including in aphasia, Alzheimer’s disease and dementia

Phone:  716-829-5565

Email:  [email protected]

Ralph H. Benedict

SUNY Distinguished Professor of Neurology

Expertise:  multiple sclerosis (MS); impact of MS, concussion and other brain diseases on personality, cognition and psychiatric stability

Email:  [email protected]

Contact:  Ralph H. Benedict can be reached through Ellen Goldbaum in University Communications at 716-645-4605 or  [email protected] , or Douglas Sitler in University Communications at 716-645-9069 or  [email protected] .

Richard Salvi

SUNY Distinguished Professor Emeritus of Communicative Disorders and Sciences

Expertise: tinnitus, hearing, noise-induced hearing loss, hyperacusis, central auditory system

Phone:  716-829-5310

Email: [email protected]

Professor of Communication

Expertise: science, health, environmental and risk communication

Phone:  716-645-1169

Email: [email protected]

Tiffany Karalis Noel

Clinical Assistant Professor of Learning and Instruction

Expertise: sociocultural inequity in education, teacher preparation and retention, mentoring in higher education

Phone:  716-645-2455

Email: [email protected]

Expertise: stress, coping

Phone: 716-645-0239

Email: [email protected]

Rohini Srihari

Professor of Computer Science and Engineering

Expertise: natural language processing, artificial intelligence, social bots, virtual assistants (Alexa, Siri), chatbots, social media mining, multilingual text mining, search

Phone:  716-645-1602

Email:  [email protected]

Veljko Fotak

Associate Professor of Finance

Expertise: international corporate finance, sovereign wealth funds, syndicated loan markets, currency markets, short selling, government interventions and equity bailouts, and the intersection of finance and politics

Contact:  Veljko Fotak can be reached most quickly through Jackie Ghosen in the School of Management Communications Office at 716-645-2833 or [email protected] .

Laura Rusche

Expertise:  yeast, genomics, genetics, gene expression, chromosomes, DNA, RNA, chromatin, sirtuins

Phone:  716-645-5198

Email:  [email protected]

Albert H. Titus

Professor of Biomedical Engineering

Expertise: biomedical engineering, wearable technology, biosensors, smart sensors

Phone:  716-645-1019

Email: [email protected]

Jorge Luis Fabra-Zamora

Associate Professor of Law

Expertise:  legal philosophy, transnational law, transitional justice, truth commissions, Colombia’s peace agreement, international human rights and compensation

Phone:  716-645-3292

Email:  [email protected]

Director of the UB RENEW Institute

Expertise:  chemicals of emerging concern; industrial pollution; wastewater treatment; environmental impact of PFAS ("forever chemicals"), PCBs, PBDEs (flame retardants), pesticides, nanomaterials, antimicrobials, pharmaceuticals and personal care products; antibiotic resistance in the environment; target and non-target analysis; Great Lakes pollution

Phone:  716-645-4220

Email: [email protected]

John J. Leddy

Director of the Concussion Management Clinic

Expertise:  concussions, post-concussion syndrome, sports medicine

Phone: 716-829-5501

Email: [email protected]

Nadine Shaanta Murshid

Associate Dean for Diversity, Equity and Inclusion

Expertise:  microfinance, mobile financial services, domestic violence, street harassment, women’s health, trauma

Phone:  716-645-5749

Email:  [email protected]

Cristian Tiu

Associate Professor and Chair of Finance

Expertise: stock market; hedge funds; financial fraud; risk management and asset allocation; institutional investors; text analysis in finance

Contact:  Cristian Tiu can be reached most quickly through Jackie Ghosen in the School of Management Communications Office at 716-645-2833 or [email protected] .

Donald A. Grinde Jr.

Professor Emeritus in the Department of Africana and American Studies

Expertise:  Native American studies, Native American thought, Haudenosaunee/Iroquois history, U.S. Indian Policy since 1871, American Indian activism

Phone:  716-645-0828

Email:  [email protected]

Sourav Sengupta

Associate Professor of Psychiatry and Pediatrics

Expertise:  Child and adolescent mental health; children’s and adolescents’ use of technology, including screen time

Email:  [email protected]

Contact: Sourav Sengupta can be reached through Ellen Goldbaum in University Communications at 716-645-4605 or [email protected], or Douglas Sitler in University Communications at 716-645-9069 or [email protected].

Timothy Maynes

Associate Professor of Organization and Human Resources

Expertise: employee-driven innovation and change; employee productivity, engagement and performance; effective team functioning (especially in sports)

Contact:  Timothy Maynes can be reached most quickly through Jackie Ghosen in the School of Management Communications Office at 716-645-2833 or [email protected] .

Natalie Simpson

Chair of Operations Management and Strategy

Expertise: emergency services and disaster response; supply chain risk and resilience; creative and temporary operations; complex networks

Contact:  Natalie Simpson can be reached most quickly through Jackie Ghosen in the School of Management Communications Office at 716-645-2833 or [email protected] .

Katherine N. Balantekin

Expertise:  obesity, disordered eating, parental influences on child eating behavior, childhood obesity, diet culture, anti-obesity drugs

Phone:  716-829-5578

Email:  [email protected]

Margaret Sallee

Professor of Educational Leadership and Policy

Expertise: university work environment, work/family policies, work/life balance, faculty diversity, gender on college campuses, graduate student experience, student-parents in college

Phone:  716-645-1091

Email: [email protected]

Charlotte Lindqvist

Expertise: evolutionary biology, evolution of polar bears, hybridization of polar bears and brown bears, genomics

Phone:  716-645-4986

Email: [email protected]

Derek Daniels

Professor and Chair of Biological Sciences

Expertise:  science of thirst; science of food, water and salt intake; ingestive/eating behaviors

Phone:  716-645-0264

Email:  [email protected]

Joyce Hwang

Associate Professor of Architecture

Expertise: animal architecture; habitecture; habitart; wildlife habitats, ecology and architecture

Phone:  716-829-5906

Email:   [email protected]

Stelios Andreadis

SUNY Distinguished Professor of Chemical and Biological Engineering

Expertise: regenerative medicine, tissue engineering, stem cells, vascular grafts

Phone:  716-645-1202

Email: [email protected]

Nicholas B. Holowka

Expertise: human movement, biomechanics of walking/running, human feet, footwear, primate locomotion, human evolution

Phone:  716-645-0444

Email: [email protected]

Mark Daniel Hicar

Associate Professor of Pediatrics

Expertise:  pediatric infectious diseases, viral infections, antibody responses against HIV, Kawasaki disease

Phone:  716-323-0150

Email: [email protected]

Chunming Qiao

SUNY Distinguished Professor of Computer Science and Engineering

Expertise: Self-driving and connected cars, specifically the computing systems for these technologies

Phone:  716-645-4751

Email: [email protected]

Lillian S. Williams

Associate Professor of Africana and American Studies

Expertise:  U.S. social and urban history; African American history in the U.S. and Western New York; women’s history

Phone:  716-645-0798

Email:  [email protected]

Sanjay Sethi

Chief of the Division of Pulmonary, Critical Care and Sleep Medicine in the Department of Medicine

Expertise: respiratory infections and lung disease, especially in chronic obstructive pulmonary disease (COPD) and lung infections, such as bronchitis and pneumonia

Phone: Sanjay Sethi can be reached through Ellen Goldbaum in University Communications at 716-645-4605 or  [email protected] , or Douglas Sitler in University Communications at 716-645-9069 or  [email protected] .

Email: [email protected]

Kate Bezrukova

Associate Professor and Chair of Organization and Human Resources

Expertise: team chemistry in business and sports; managing a diverse workforce; unconscious bias at work; negotiations and gender; work-life balance; conflict management; artificial intelligence in teams

Contact:  Kate Bezrukova can be reached most quickly through Jackie Ghosen in the School of Management Communications Office at 716-645-2833 or [email protected] .

Andrew Talal, MD

Expertise: diagnosing and treating hepatitis C virus, developing and evaluating new therapies for liver disease  

Phone:  716-829-6208

Email: [email protected]

Stuart M. Evans

Expertise: climate change, dust and dust storms, weather, atmospheric science, precipitation, monsoons, lake effect snow

Phone:  716-645-0491

Email: [email protected]

Joann Sands

Clinical Assistant Professor of Nursing

Expertise: disaster response education and training; emergency preparedness and management; the role of nurses in disasters

Phone:  716-829-2342

Email: [email protected]

Ryan M. Rish

Assistant Professor of Learning and Instruction

Expertise: adolescent literacy practices; culture and identity in learning; teaching social issues

Phone:  716-645-4042

Email: [email protected]

Dominik Roesch

Expertise: arbitrage, liquidity, international markets, market efficiency, market microstructure

Contact:  Dominik Roesch can be reached most quickly through Jackie Ghosen in the School of Management Communications Office at 716-645-2833 or [email protected] .

Joanne Song McLaughlin

Associate Professor of Economics

Expertise: labor economics; health insurance mandates; age discrimination; older workers; AI and the future of work

Phone:  716-645-8685

Email: [email protected]

Marina Oktapodas Feiler

Assistant Professor of Epidemiology and Environmental Health

Expertise:  maternal and pediatric exposure to toxic chemicals, exposure to lead and ‘forever chemicals,’ impacts on immune function including vaccine response, infectious and allergic respiratory disease. 

Phone:  716-829-2976

Email: [email protected]

Frank A. Scannapieco, DMD, PhD

SUNY Distinguished Professor of Oral Biology

Expertise: link between oral and overall health; oral health care in hospitals and nursing homes; dental plaque

Phone:  716-829-3373

Email: [email protected]

Samina Raja

Professor of Urban and Regional Planning 

Expertise: food access, food systems planning, food and urban planning, local government food policy

Phone:  716-829-5881

Email: [email protected]

Assistant Professor of Biological Sciences

Expertise: plant natural products, medicinal plants, synthetic biology, metabolic engineering

Phone:  716-645-4969

Email: [email protected]

Tevfik Kosar

Expertise:  big data, cloud computing, distributed systems, high-performance computing, green computing, energy-efficient systems

Phone:  716-645-2323

Email: [email protected]

Marion Werner

Professor of Geography

Expertise:  global trade; agriculture, food, labor rights and trade; agri-business; development in Latin America and the Caribbean

Phone:  716-645-0475

Email:  [email protected]

Carleara Weiss

Research Assistant Professor

Expertise:  behavioral sleep medicine, aging, cognitive function, biomarkers of neurodegeneration, oncology, health disparities

Phone:  716-829-3261

Email:   [email protected]

Chair and Professor of Linguistics

Expertise:  morphology, syntax, evolution of languages, endangered languages, language documentation, multilingualism

Phone:  716-645-0126

Email:  [email protected]

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• v.9(8); 2017 Aug

Dialysis: A Review of the Mechanisms Underlying Complications in the Management of Chronic Renal Failure

Sabitha vadakedath.

1 Biochemistry, Chalmeda Anand Rao Institute of Medical Sciences

Venkataramana Kandi

2 Department of Microbiology, Prathima Institute of Medical Sciences

Chronic renal failure (CRF) is the most prevalent, worldwide public health problem of the elderly population. The main cause of CRF is a damaged kidney. There are five stages of CRF based on the glomerular filtration rate (GFR), and stage 5 (GFR < 15 ml/min/1.73m 2 ) is often called an end-stage renal disease (ESRD). In CRF, there is an accumulation of toxins and excess water due to compromised renal function. Dialysis is the preferred way to treat ESRD and remove accumulated toxins from the body. The cardiovascular risk associated with dialysis is 10 to 20 times higher in patients undergoing dialysis than in normal people. The inflamed kidneys and the process of dialysis also affect endothelial function, aggravating the risk of hypertension and cardiac problems. Therefore, both physicians and patients should be aware of the consequences of undergoing dialysis. There is an urgent need to educate CRF patients regarding facts about the disease, medications, dietary habits, and various measures required to manage the condition and lead a normal life. This paper attempts to delineate the mechanisms that could result in cardiovascular and other complications among CRF patients undergoing dialysis.

Introduction and background

The process of removal of waste and extra water from blood is called dialysis [ 1 ]. It is an artificial replacement of kidney functioning, especially in renal failure cases. Dialysis cannot completely perform lost kidney function, but, to some extent, manages its activities by means of diffusion and ultrafiltration [ 2 ]. It is done in chronic renal failure (CRF) when the glomerular filtration rate falls below 15 ml/min/1.73m 2  [ 3 ]. CRF is a condition where there is a loss of kidney function over a period of months or years. CRF can be diagnosed by measuring serum creatinine levels, which are a degradative product of muscle protein. Creatinine levels indicate the glomerular filtration rate (GFR) and in CRF, its activities are raised, indicating a lowered GFR [ 4 ]. There are five stages of CRF based on the GFR, and dialysis is preferred in stage 5 (GFR < 15 ml/min/1.73m 2 ); this stage is also called end stage renal disease (ESRD) [ 5 ]. Dialysis is performed in CRF patients to remove accumulated toxins from the body. This procedure may be responsible for the development of oxidative stress, due to an imbalance between the overproduction of reactive oxygen species or toxins and a reduced defense mechanism of the body [ 4 ]. Oxidative stress disrupts the normal functioning of the cell. It was observed in a previous study that, in CRF, there could be raised plasma urate levels, further compromising the defensive mechanism of the body and increasing the oxidative stress [ 5 ].

The force with which blood flows through a blood vessel when the heart pumps blood is called blood pressure (BP), and it is measured with the help of a sphygmomanometer. In a normal, healthy person, the BP is 120/80 mmHg (systolic pressure (heart pumps)/diastolic pressure (heart relaxes)). If it is 140/90 mmHg, it is considered hypertension [ 6 ]. Hypertension increases the pressure of blood flow, which may damage blood vessels. In case renal blood vessels are involved, it leads to the accumulation of toxins and fluids, which further increases the blood pressure [ 7 - 8 ]. It is a known fact that hypertension alone is a risk factor for kidney diseases, and if it is associated with other complications, it leads to CRF.

The present paper elaborates the process of dialysis and how it influences the already nonfunctional kidneys (CRF). We also attempt to envisage the cardiovascular risk and metabolic abnormalities involved as a result of dialysis. The paper also focuses on the role of hypertension in kidney diseases and the associated cardiac risk among CRF patients.

The artificial process involving the removal of wastes and excess water from the blood is called dialysis. The criteria for undergoing dialysis is mainly disturbed renal functioning. Uremic syndrome, hyperkalemia, extracellular volume expansion, acidosis, not responding to medical therapy, creatinine clearance of 10 ml/min/1.73 m 2 , and bleeding diathesis (susceptibility to bleed due to coagulation defects) are the criteria for dialysis [ 9 - 11 ].

The renal functional capacity can be assessed by measuring serum creatinine/blood urea nitrogen (BUN) or by urea and creatinine clearance. There are two types of dialysis procedures; it may be hemodialysis (using a machine/artificial kidney-like apparatus) or peritoneal dialysis (using a peritoneal membrane as a filter). Peritoneal dialysis is recommended for younger patients because of its flexibility and can be performed at home. Hemodialysis is done for patients with no residual renal function. 

The mechanism of hemodialysis

In hemodialysis, the wastes and excess water are removed by using an external filter called a dialyzer, which contains a semipermeable membrane. The separation of wastes is done by creating a counter-current flow gradient, where blood flow is in one direction and the fluid of the dialyzer is in the opposite direction. Peritoneal dialysis uses the peritoneum as a natural semipermeable membrane and removes waste and water into the dialysate (the material or fluid that passes through the membrane of the dialysis).

The basic principle involved in dialysis is the movement or diffusion of solute particles across a semipermeable membrane (diffusion). Metabolic waste products, such as urea and creatinine, diffuse down the concentration gradient from the circulation into the dialysate (sodium bicarbonate (NaHCO 3 ), sodium chloride (NaCl), acid concentrate, and deionized water). During their diffusion into the dialysate, the size of particles, in turn, determines the rate of diffusion across the membrane. The larger the size of the solute particle, the slower is the rate of diffusion across the membrane. Here, arteries carrying oxygenated blood from the heart are connected to a vein forming an arteriovenous shunt, which makes the vein strong (by forming muscles around it like an artery) enough to be punctured many times; its pressure is also monitored during the process of dialysis. The diagrammatic representation of a dialyzer is shown in Figure  1 .

NaHCO 3 : sodium bicarbonate; NaCl: sodium chloride

Cardiovascular complications and dialysis

Dialysis could be associated with moderate (hypotension, muscle cramps, anaphylactic reactions) to severe (cardiovascular disease (CVD)) complications. Ongoing inflammation is the main reason for the diseased kidney, which does not respond to medications. Chronic inflammation disturbs the normal functioning of the kidneys, resulting in the accumulation of metabolic wastes in the body. The process of dialysis helps in the removal of toxins from the body and, slowly, the kidney may regain its function; this depends on the age and the health condition of the individual, as shown in Figure  2 .

The presence of inflammation is an important factor in the development of oxidative stress in patients undergoing dialysis. During the process of dialysis, the membrane of dialysis is subjected to an immunological response by low molecular weight substances that include the IgG, the complement component, and makes this membrane permeable to granulocytes. The activated granulocytes in the blood stimulate the release of reactive oxygen species (ROS) and exaggerate the oxidative stress. It was also found that there are reduced trace elements, such as copper and zinc, and superoxide dismutase (SOD) levels among post-dialytic persons [ 12 - 13 ]. The nonfunctioning kidney activates macrophages, vascular cells, and various glomerular cells to produce free radicals, which further aggravate the oxidative stress, leading to a sequential change in organs, resulting in multiple organ failures and then death. Hypertension (uncontrolled due to inadequate treatment), hyperlipidemia, homocysteinemia, anemia, and the calcification of coronary arteries are the risk factors for CVD in dialysis patients. All these risk factors, alone or in combination, can alter cardiovascular dynamics [ 14 - 15 ].

Thyroid dysfunction and dialysis

Thyroid hormones influence protein synthesis and cell growth, as evidenced by previous studies, which showed accelerated thyroid functioning during renal development in neonatal rats [ 16 ]. As a result, disorders of thyroid and kidney exist with a common etiological factor [ 17 ]. Thyroid function (low triiodothyronine (T 3 ) levels) can be altered in dialysis, which may be attributed to the underlying cause—the inflammation. It was observed in experimental and clinical studies that interleukin signaling downregulates the peripheral conversion of tetraiodothyronine/thyroxine (T 4 ) to T 3 (Inhibition of 5'-deiodinase enzyme) . The low levels of T 3  are associated with left ventricular hypertrophy and are considered as cardiovascular markers [ 18 - 20 ]. A flow chart demonstrating the side effects of inflammation associated with dialysis is shown in Figure  3 .

IL-1: interleukin 1; T 3 : triiodothyronine; T 4 : tetraiodothyronine/thyroxine

Although dialysis is the preferred way to regain the functional ability of the kidneys, it could be responsible for certain side effects that include oxidative stress, thyroid disorders, and heart problems. Dialysis prolongs the life of an individual but cannot cure the underlying problem, so it is evident that the complications of dialysis could be due to the inflammation within the kidney.

Inflammation and dialysis

The inflammation of the kidneys may alter endothelial function, which could lead to decreased nitric oxide (NO) availability. The endothelial dysfunction can be predicted by the increased activities of asymmetric dimethyl arginine (ADMA). ADMA is an inhibitor of the enzyme "NO synthase," which is normally cleaved within the kidney [ 21 ]. Endothelial dysfunction also leads to proteinuria due to increased vascular permeability [ 22 ]. The improper functioning of kidneys disturbs several enzymes and receptors involved in lipoprotein metabolism (apo A1 (apolipoprotein A1)), particularly the high-density lipoproteins (HDL) and triglyceride-rich lipoproteins (chylomicrons, very low-density lipoproteins (VLDL), and low-density lipoproteins (LDL)) leading to hyperlipidemia [ 23 ]. It also causes the improper clearance of homocysteine, a sulfur-containing amino acid causing hyperhomocysteinemia and vitamin B 12 deficiency anemia due to its influence on methionine synthase (an enzyme that helps to convert homocysteine to vitamin B 12 ) [ 24 ].

Kidney dysfunction alters the lumen of blood vessels by inhibiting the cross-linking of collagen, making them atherogenic (narrows the lumen of the vessels) [ 25 ]. The kidney dysfunction may also affect the clearance of calcium and phosphorus, which could be responsible for the calcification of major arteries such as coronary arteries [ 26 ]. The calcification of major arteries can be assessed by measuring a glycoprotein, osteoprotegerin (OPG) [ 27 ]. The mechanism underlying kidney dysfunction and its effect on blood pressure and other metabolites is shown in Figure ​ Figure4 4 . 

ADMA: asymmetric dimethyl arginine; HDL: high-density lipoproteins; NO: nitric oxide; apo A1: apolipoprotein A1

In patients undergoing dialysis, there is an increased probability that the inflammation of the kidneys is accelerated, leading to further complications. Although the causes of inflammation are multifactorial, as discussed earlier, they also depend greatly on the membrane biocompatibility and the quality of dialysate. During dialysis, there is a possibility of the retention of inflammatory markers, the development of oxidative imbalance, and the activation of the complement [ 28 - 29 ]. CRF patients undergoing hemodialysis are at increased risk of developing several conditions, which include anemia, bleeding disorders, infection, electrolyte abnormalities, and cardiovascular dysfunction [ 30 - 32 ].

Conclusions

In CRF patients, dialysis is the best method to remove accumulated toxins from the body and improve the quality of life. But this process, by itself, may complicate the condition due to its side effects. Individuals suffering from CRF, who are on dialysis, could be at increased cardiovascular and metabolic risk. Nowadays, dialysis is vigorously used even for small, treatable issues of the kidney.Therefore, the consequences of undergoing dialysis should be made known to both the physicians and the patients. There is an urgent need to educate CRF patients about facts related to the disease, medications, dietary habits, and the various measures required to manage the condition and lead a productive life.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.