OBJECTIVE

Depressive symptoms are commonly noted in patients on hemodialysis treatment. The objective of the present study was to evaluate the psychological care of patients receiving in-center hemodialysis treatment. Thus the aim was to describe the occurrence of depressive symptoms and prescription of antidepressive agents, as well as to assess the agreement between present symptoms and ongoing pharmacological treatment in clinical practice.

METHODS

The occurrence of self-reported depressive symptoms and documented ongoing pharmacological treatment was assessed in a cross-sectional survey including 141 hemodialysis patients. Agreement between depressive symptoms and prescription of antidepressants was analyzed.

RESULTS

Thirty-five percent of the participants suffered from self-reported depressive symptoms, and there was poor agreement between depressive symptoms and prescription of an antidepressant agent.

DISCUSSION

Depressive symptomatology is a significant problem in hemodialysis patients. It is therefore important to use systematic approaches to screen patients for depression, diagnose clinical depression, plan for treatment strategies, and follow up depression treatment outcomes.

This thesis is comprised of four studies and concerns haemodialysis patients’ confidence in being able to manage fluid intake between treatment sessions, and whether the fluid intake is influenced by certain modifiable characteristics of the persons in question. The overall aim was to study aspects of excessive fluid overload and haemodialysis patients’ self-regulation of fluid allotment from a bio-psychosocial and behavioural medicine perspective.

The extent of non-adherence to fluid allotment was described in Study I. National registry data were used. Three out of ten Swedish haemodialysis patients had excessive fluid overload and one out of five was at risk for treatment related complications due to too rapid ultrafiltration rate.

The objective in Study II was to develop and psychometrically evaluate a self-administered scale to measure situation-specific self-efficacy to low fluid intake. The measure (the Fluid Intake Appraisal Inventory) was found to be reliable and valid in haemodialysis settings.

Subgroups based on individual profiles of self-efficacy, attentional style and depressive symptoms were explored in Study III using a cluster analytic approach. Three distinct subgroups were found and the subgroup structure was validated for clinical relevance. The individuals’ profile concerning self-efficacy, attentional style and depressive symptoms has to be taken into account in nursing interventions designed to reduce haemodialysis patients’ fluid intake.

In Study IV, an intervention designed to reduce haemodialysis patients’ fluid intake was introduced and its acceptability, feasibility and efficacy were evaluated and discussed. Acceptability of such an intervention was confirmed. Addressing beliefs, behaviours, emotions and physical feelings is clinically feasible and may reduce haemodialysis patient’s excessive fluid overload.

This thesis indicates that there is a potential for improvement in the fluid management care of haemodialysis patients. Behavioural nursing strategies that aim to assist patients to achieve fluid control should be applied more extensively. Cognitive profiles of the patients should be taken into account when targeted nursing intervention aiming to encourage and maintain the patient’s fluid control is introduced.

Excessive fluid overload is common in hemodialysis patients. Understanding fluid intake behavior in relation to used cognitive coping style would serve the fluid restriction consultation. The aim of this study was to explore whether hemodialysis patients' fluid intake behavior differs as a function of used coping style. Secondary analysis of data from 51 hemodialysis patients regarding cognitive coping style (assessed by the Threatening Medical Situations Inventory) and fluid intake behavior were used. The participants' mean age was 62.9 years (range 27-84), they had received dialysis treatment for 3.9 years on average (range 0-22), 63% were male and they had gained 3.6% (±1.3) of their dry body weight during the interdialytic period. There was a significant difference in fluid intake behavior between coping groups (F = 3.899, d.f. 2, P = 0.027). The difference (P = 0.028) was isolated between patients with cognitive blunting style and patients with neutral coping style. Identification of hemodialysis patients using cognitive avoidance strategies can be advantageous in renal care. Fluid advice provided may have to be adjusted to the used coping style, especially for patients with a blunting coping style. However, the findings need to be confirmed, and the effect of individualized counseling needs to be evaluated in forthcoming studies.

Background:The concept of dry weight is central to fluid control in patients on haemodialysis (HD). Few studies have explored the concept from the patient perspective. Thus, the aim of the present study was to explore how patients on HD perceive the concept of dry weight and how they act in relation to it.

Methods:A purposive sample of 10 HD patients was interviewed once during a dialysis session in May–June 2009. The narratives were analysed using manifest qualitative content analysis.

Findings: The findings indicated that the concept was regarded as either an aid to securing treatment-related health, as indicating the fluid surplus volume or as a reminder of the daily fluid allotment. Some informants, however, did not report any specific perception. Plans for dealing with the perceptions were expressed in terms of using self-care strategies to control fluid balance, transferring responsibility to the HD team, and managing the physical consequences or social and psychological concerns.

Conclusion: Four ways in which HD patients perceived the dry weight concept were demonstrated. It is important that HD patients understand the significance of dry weight, both for their own wellbeing and for treatment adequacy. Prevalent misunderstandings about the dry weight concept have to be addressed by the dialysis team in order to prevent further suffering. By acknowledging the patient’s perspective of the dry weight concept, the dialysis team could help the patient to successfully develop self-care strategies for dealing with the consequences of chronic renal failure.

Self-efficacy is a temporary and influenceable characteristic, related to situations and tasks, mediating health-promoting behaviours. This study aimed to evaluate psychometric properties of a Portuguese version of the Fluid Intake Appraisal Inventory, and to describe self-efficacy in relation to limited fluid intake amongst Portuguese haemodialysis patients. Respondents were recruited from three dialysis units, and 113 of 155 eligible patients gave their informed consent. The translated scale was distributed and collected by the head nurses. Interdialytic weight gain was calculated as percentage of dry weight. Satisfactory psychometric properties were estimated in the Portuguese context. The participants' self-efficacy in relation to low fluid intake was asymmetrically distributed; the majority had moderately to high self-efficacy while some patients had very low self-efficacy to limited fluid intake. There was a significant difference in self-efficacy to fluid restrictions; patients with a weight gain of 3.5% or less presented higher self-efficacy scores than did patients exceeding the cutoff point.

The aim of this study was to describe essential competencies relevant for professional renal nursing in Sweden. A Delphi study with four rounds was conducted from November 2008 to April 2009. A national sample of renal nurses was used to achieve consensus about the core competencies required. The 43 competencies were reviewed for face validity by external experts representing general nursing, renal nursing, stakeholders and nephrologists. The core competencies were categorised in nine areas according to their structure; nursing and medical science, information and teaching, examinations and therapies, promoting health and preventing ill health, palliative care, safety and quality, care environment, research and development and management and cooperation in the patient care pathway. Altogether these categories represent a national description of competence in renal nursing.

Excessive interdialytic weight gain (IWG) and ultrafiltration rates (UFR) above 10 mL/h/kg body weight imply higher morbidity and mortality. This study aimed to estimate the prevalence of high fluid consumers, describe UFR patterns, and describe patient characteristics associated with IWG and UFR. The Swedish Dialysis DataBase and The Swedish Renal Registry of Active Treatment of Uremia were used as data sources. Data were analyzed from patients aged ≥18 on regular treatment with hemodialysis (HD) and registered during 2002 to 2006. Interdialytic weight gain and dialytic UFR were examined in annual cohorts and the records were based on 9693 HD sessions in 4498 patients. Differences in proportions were analyzed with the chi-square test and differences in means were tested using the ANOVA or the t test. About 30% of the patients had IWG that exceed 3.5% of dry body weight and 5% had IWG ≥5.7%. The volume removed during HD was >10 mL/h/kg for 15% to 23% of the patients, and this rate increased during the first dialytic year. Patient characteristics associated with fluid overload were younger age, lower body mass index, longer dialytic vintage, and high blood pressure. By studying IWG and dialytic UFR as quality indicators, it is shown that there is a potential for continuing improvement in the care of patients in HD settings, i.e., to enhanced adherence to fluid restriction or alternatively to extend the frequency of dialysis for all patients, e.g., by providing daily treatment.

Aim.  To describe and perform a tailored treatment programme based on a behavioural medicine approach to enhance haemodialysis patients’ self-management of fluid restriction.

Background.  Haemodialysis patients are required to manage dietary restrictions within a framework of adequate nutrition. Adherence to limited fluid allotment is important but difficult to accomplish. Pragmatic and effective ways of helping patients with fluid management are lacking.

Methods.  Cognitive-behavioural techniques were used in four quasi-experimental case studies. Central features in the programme were individual analysis of dietetic knowledge and fluid intake, setting goals, self-monitoring and prevention of relapse. Fluid overload was continuously assessed. Data were collected from September 2009–March 2010.

Findings.  Acceptability and feasibility of the intervention was satisfactory. A clear reduction of fluid overload was shown. Some problems related to treatment fidelity were identified.

Conclusions.  The behavioural medicine approach resulted in a clear reduction of fluid overload in each of the four cases included.

Relevance to clinical practice.  This approach could be used as a method for tailoring interventions targeted to fluid intake behaviour in a heterogeneous group of HD patients with excessive fluid overload. Such treatment should take account of individual cognitive-behavioural patterns and include self-efficacy to low fluid intake. The efficacy of the tailored approach in regular practice has to be further tested in controlled trials.

AIMS: To determine whether definable subgroups exist in a sample of haemodialysis patients with regard to self-efficacy, attentional style and depressive symptomatology and to compare whether interdialytic weight gain varies between patients in groups with different cognitive profiles.

BACKGROUND: Theory-based research suggests that cognitive factors (e.g. self-efficacy and attentional style) and depressive symptomatology undermine adherence to health protective regimens. Preventing negative outcomes of fluid overload is essential for haemodialysis patients but many patients cannot achieve fluid control, and nursing interventions aimed to help the patients reduce fluid intake are ineffective. Understanding the interaction between cognitive factors and how this is related to adherence outcomes might therefore lead to the development of helpful nursing interventions.

DESIGN: Explorative cross-sectional multicentre survey.

METHODS: The sample consisted of 133 haemodialysis patients. Data were collected using structured questionnaires. A brief self-report form and data on interdialytic weight gain was also used. Two-step cluster analysis was used to identify subgroups. One-way analysis of variance (anova) or Pearson's chi-square test was used for comparing subgroups.

RESULTS: Three distinct subgroups were found and subsequently labelled: (1) low self-efficacy, (2) distraction and depressive symptoms and (3) high self-efficacy. The subgroups differed in fluid intake, but not in age, dialysis vintage, gender, residual urine output or in receiving any fluid intake advice.

CONCLUSIONS: Clinically relevant subgroups of haemodialysis patients could be defined by their profiles regarding self-efficacy, attentional style and depressive symptoms.

RELEVANCE TO CLINICAL PRACTICE: Based on this study, we would encourage clinical practitioners to take into account cognitive profiles while performing their work. This is especially important when a targeted nursing intervention, which aims to encourage and maintain the patient's fluid control, is introduced.

Background

Management of hydration status in dialysis patients is a great challenge to nephrologists, and new tools to understand the hydration status (HS) are needed. The aim of this study was to investigate the usefulness of brain natriuretic peptide (BNP), analyzed bedside, as a marker of overhydration (OH) in hemodialysis (HD) patients.

Methods

We investigated the distribution of BNP, measured by Alere Triage® BNP Test, and analyzed the correlation between BNP and HS, defined by bioimpedance spectroscopy (BIS) in 64 HD patients. We assumed there would be a difference in HS between patients with high levels of BNP (h-BNP) and low levels of BNP (l-BNP) and choose an arbitrary cut off of 500 ng/ml, and then differences between the groups were tested for significance. HS, blood pressure (BP) and heart rate was measured, and BNP analyzed, before one mid-week dialysis session. Blood samples were also drawn for analysis of NT-proBNP and inflammatory markers. Demographic data, comorbidities, lab values and nutritional status were collected from medical records.

Results

A positive correlation was found between BNP and OH (r = 0.4), although many severely overhydrated patients had normal or just slightly elevated BNP. BNP levels were above 500 in 38 % (n=24) of the participants. The level of OH before dialysis was higher in the h-BNP group than in the l-BNP group. There was no difference in BP before or after dialysis, but patients in the h-BNP group were older, had lower muscle strength and lower Hemoglobin and Albumin levels compared to the l-BNP group.

Conclusion

A normal BNP does not rule out OH as defined by BIS in HD patients, on the other hand euvolemia was rare in patients with elevated BNP. This suggests that BNP might serve as a marker of OH in a subgroup of old and frail patients. In a further study we aim to investigate if the relationship between BNP, when elevated, and OH is reproducible at an individual level.

BACKGROUND: Inadequate volume control may be a main contributor to poor survival and high mortality in hemodialysis patients. Bioimpedance measurement has the potential to improve fluid management, but several dialysis centers lack an agreed fluid management policy, and the method has not yet been implemented. Our aim was to identify renal care professionals' perceived barriers and facilitators for use of bioimpedance in clinical practice.

METHODS: Qualitative data were collected through four focus group interviews with 24 renal care professionals: dieticians, nephrologists and nurses, recruited voluntarily from a nation-wide selection of hemodialysis centers, having access to a bioimpedance-device. The participants were connected to each other and a moderator via equipment for telemedicine and the sessions were recorded. The interviews were semi-structured, focusing on the participants' perceptions of use of bioimpedance in clinical practice. Thematic content analysis was performed in consecutive steps, and data were extracted by employing an inductive, interactive, comparative process.

RESULTS: Several barriers and facilitators to the use of bioimpedance in clinical practice were identified, and a multilevel approach to examining barriers and incentives for change was found to be applicable to the ideas and categories that arose from the data. The determinants were categorized on five levels, and the different themes of the levels illustrated with quotations from the focus groups participants.

CONCLUSIONS: Determinants for use of bioimpedance were identified on five levels: 1) the innovation itself, 2) the individual professional, 3) the patient, 4) the social context and 5) the organizational context. Barriers were identified in the areas of credibility, awareness, knowledge, self-efficacy, care processes, organizational structures and regulations. Facilitators were identified in the areas of the innovation's attractiveness, advantages in practice, and collaboration. Motivation, team processes and organizational capacities appeared as both barriers and facilitators.

Overhydration is an independent predictor of mortality in hemodialysis (HD) patients. More than 30% of HD patients are overhydrated, motivating the development of new methods for assessing hydration status. This study surveyed clinical praxis and local guidelines for dry weight (DW) assessment in Swedish and Danish HD units, and examined if differences in routines and utilization of bioimpedance spectroscopy (BIS) and other assistive technology affected frequency of DW adjustments and blood pressure (BP) levels. Cross-sectional information on praxis, guidelines and routines, plus treatment-related data from 99 stratified patients were collected. Qualitative data were analyzed with content analysis and interpreted in convergence with statistical analysis of quantitative data in a mixed-methods design. Local guidelines concerning DW existed in 54% of the units. A BIS device was present in 52%, but only half of those units used it regularly, and no correlations to frequency of DW adjustments or BP were found. HD nurses were authorized to adjust DW in 60% of the units; in these units, the frequency of DW adjustments was 1.6 times higher and systolic BP pre-HD 8 mmHg lower. There is a wide variation in routines for DW determination, and there are indications that authorization of HD nurses to adjust DW may improve DW assessment. BIS is sparsely used; its implementation may have been delayed by uncertainty over how to manage the device and interpret measurements. Hence, better methods and guidelines for assessing DW and using BIS need to be developed.

Many haemodialysis patients have problems limiting their fluid intake, and this might be influenced by their self-efficacy. Thus interventions to improve patients' self-efficacy might lead to an improvement in their adherence to fluid restriction. The fluid intake appraisal inventory (FIAI) evaluates patients' self-efficacy with regard to fluid intake. The aim of this study was to translate and validate the FIAI for use in the Netherlands. Four translators, seven experts, and four haemodialysis patients participated in the translation part of the study. Thirty-three patients from one dialysis centre in the Netherlands completed the Dutch FIAI. The instrument had good content validity (interdialytic weight gain was found to be negatively correlated with self-efficacy), internal consistency (Cronbach's alpha = 0.982), and stability (Spearman's rho = 0.823). These findings indicate that the Dutch FIAI can be used in clinical practice as a self-efficacy screening instrument for adult haemodialysis patients on fluid restriction.

Aim Little is known about the health-related quality of life (HRQoL) of children with lower urinary tract dysfunction (LUTD) and chronic kidney disease (CKD). We investigated LUTD and other possible predictors of impaired HRQoL in children with conservatively treated moderate to severe CKD or with a kidney transplant.

Methods All 64 children with CKD or a kidney transplant treated at Karolinska University Hospital, Stockholm, Sweden, between June 2011 and December 2012 were approached and 59 children aged 8-18 were enrolled in the study. Lower urinary tract function was evaluated with voiding history, frequency and volume chart, uroflowmetry and post void ultrasound measurements. Self-reported HRQoL was assessed with validated generic instruments.

Results The HRQoL of the study cohort was as good as the general paediatric population, apart from the physical and psychological well-being dimensions, and was no different to children with other chronic conditions. Urinary incontinence, but not LUTD in general, was associated with impaired HRQoL, as was having a kidney transplant and being female in some dimensions.

Conclusion LUTD was common in children with CKD or a kidney transplant but did not affect their general HRQoL. Predictors of impaired HRQoL included incontinence, having had a kidney transplant and being female.