Working for the Weekend: The Effect of Cognitive Functioning, Social Support, and the Interdialytic Interval on Disease Self-Management Among Patients on Hemodialysis

End-stage renal disease is a chronic, terminal condition in which the kidneys retain less than 5% of their normal capacity for filtering wastes and fluids from the bloodstream. Kidney failure represents a significant and costly public health problem, especially for Hispanic patients. While there are no known direct psychosocial causes of kidney failure, sociobehavioral factors play a crucial role in determining the capacity for survival for the end-stage renal disease patient; in addition to taking on dialysis treatment, in which an artificial kidney filters waste products from the body, patients must take dozens of medications and monitor and restrict their diet and fluid intake, resulting in high disease burden, high cognitive demand, and high risk for morbidity and mortality. Additionally, changes in cognitive and psychosocial functioning over the course of the dialytic cycle may be crucial in determining treatment outcomes for these patients. The purpose of the present study was to examine the interrelationships between cognitive functioning, general and disease-specific social support, and the length of the interdialytic interval on adherence to treatment in a sample of patients on hemodialysis. The study was the first to explore these relationships using a sophisticated electronic diary system. Participants included 22 (female n = 11; Mean age 44 years) English- and Spanish-speaking, primarily Hispanic patients being treated for kidney failure at the UC Irvine Medical Center. Overall, levels of social support in this sample were high, and reports of cognitive dysfunction were minimal. Some aspects of social support, particularly diet-related support, were associated with improved adherence to treatment, but in general, support did not substantially influence engagement in behaviors of disease self-management. Additionally, contrary to hypotheses, cognitive functioning was greater over two-day interdialytic intervals than shorter one-day intervals, and was not found to mediate the relationship between length of the interdialytic interval and disease self-management. Likewise, the effect of cognitive functioning on treatment adherence was not buffered by social support. Such findings provide some limited support for an osmotic theory of cognitive dysfunction resulting from hemodialysis, but should interpreted with caution pending recruitment of a larger sample and a higher degree of compliance with the ecological momentary assessment protocol

Negative Emotions and Risk for Type 2 Diabetes among Korean Immigrants

PurposeThe purpose of this study is to examine the relationship between negative emotions and bio-behavioral risk factors among Korean immigrants at risk for type 2 diabetes (T2DM).MethodsData were collected from 148 Korean immigrant adults who are “at risk” for T2DM as defined by having family history of T2DM in first degree relatives, body mass index greater than 23, or history of gestational diabetes in women. Participants completed questionnaires and underwent biological measures. Negative emotions included feeling nervous, hopeless, restless, anxious, and stressed as well as depressive symptoms.ResultsHigh percentages of participants had T2DM risk factors including overweight, greater than normal waist to hip ratio, and blood glucose readings that are indicative of T2DM. Feeling stressed was the most commonly reported negative emotion (66%), followed by feeling anxious (51%), restless (38%), nervous (30%), and hopeless (13%). Experience of negative emotions was significantly related to behavioral risk factors; higher levels of experiencing negative emotions were related to increased soda intake and a decreased likelihood of doing at least 10 minutes of moderate exercise. Stress and anxiety were each negatively related to moderate exercise and depressive symptoms were negatively related to both moderate and vigorous exercise. No significant relationship was found between negative emotions and biological risk factors.ConclusionsFindings suggest that negative emotions, individually and taken together, may be related to T2DM risk behaviors in high-risk Korean immigrants. Behavioral interventions to prevent T2DM in this population should consider assessing and addressing negative emotions

The effect of the interdialytic interval on cognitive function in patients on haemodialysis

BACKGROUND:Cognitive deficits are common among individuals on haemodialysis (HD). The degree of dysfunction may shift over the course of the interdialytic interval. OBJECTIVES:To use ecological momentary assessment (EMA) to examine the relationship between the length of the interdialytic interval and reports of cognitive dysfunction. DESIGN:A quantitative study whereby each patient's cognitive functioning was measured during both short and long interdialytic intervals. PARTICIPANTS:Adults maintained on HD (Female n = 15, Male n = 11; MAge  = 42.7 ± 15.8 years) were drawn from a standalone HD unit within a large university medical centre. MEASUREMENTS:Tests of baseline neurocognitive functioning were undertaken (Mini-Mental Status Examination, Digit Span, California Verbal Learning Test, Benton Visual Retention Test, Trail-Making Test) and smartphone-based electronic diary reports of cognitive impairment were made around six times each day for one week. RESULTS:Cognitive function and aptitude in this sample, although low, did not reflect clinically-significant impairment, with a mean Mini-Mental Status Exam score of 25.7 ± 3.0. Diary reports of cognitive impairment were also minimal, with an overall mean rating of .22 out of 5. Contrary to expectations, cognitive impairment was significantly greater on the one-day interdialytic days than on Day 2 of the two-day interdialytic interval (β = .094, p = .017). CONCLUSIONS:Although cognitive impairment appears to be mild in stable, young patients with end stage renal disease, volumetric disruptions caused by HD may exacerbate such dysfunction

Correction to: Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters.

In the original publication, age stratified mortality rates were incorrectly added in Fig. 2. The correct Fig. 2 is given below

Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters.

PURPOSE:The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD. METHODS:A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics. RESULTS:Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk. CONCLUSION:Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making

Recommendations for Systematizing Transplant Education Within a Care Delivery System for Patients With Chronic Kidney Disease Stages 3 to 5.

ContextEarly tailored transplant education could help patients make informed transplant choices.ObjectiveWe interviewed 40 patients with chronic kidney disease (CKD) stages 3 to 5, 13 support persons, and 10 providers at Kaiser Permanente Southern California to understand: (1) barriers to transplant education and (2) transplant educational preferences and recommendations based on CKD stage and primary language spoken.DesignA grounded theory analysis identified central themes related to transplant education barriers, preferences, and recommendations.ResultsBarriers included confusion about diagnosis and when transplant may be necessary, concerns about transplant risks, families' lack of transplant knowledge, financial burdens, transportation and scheduling, and the emotional overload of chronic illness. Hispanic and Spanish-speaking participants reported difficulty in understanding transplant education and medical mistrust. Recommendations included providing general education, earlier introduction to transplant, wait-listing information, transplant education for support persons, living donation education for patients and potential donors, opportunities to meet living donors and kidney recipients, information on the benefits of transplant, recovery, and available financial resources, flexible class scheduling, online and print resources, and more provider follow-up. Spanish-speaking and Hispanic participants recommended using bilingual educators, print, video, and online resources in Spanish, and culturally responsive education. Patients with CKD stages 3 to 4 wanted information on slowing disease progression and avoiding transplant.ConclusionIncreasing access to culturally responsive transplant education in multiple languages, pairing appropriate content to the disease stage, and increasing system-wide follow-up as the disease progresses might help patients make more informed choices about transplant

A randomized controlled trial of Explore Transplant at Home to improve transplant knowledge and decision-making for CKD 3–5 patients at Kaiser Permanente Southern California

Abstract Background Five-year survival on dialysis is only 40%, compared to 74% with a deceased donor kidney transplant (DDKT) and 87% with a living donor kidney transplant (LDKT). An American Society of Transplantation (AST) Consensus Conference recommended that patients with chronic kidney disease (CKD) Stages 3–5 have the opportunity to learn about and decide which treatment option is right for them, particularly about LDKT. However, early education about LDKT and DDKT outside of transplant centers is inconsistent and often poor, with patients in CKD 3 and 4 and ethnic/racial minorities even less likely to receive it. A new randomized control trial (RCT), in partnership with Kaiser Permanente Southern California (KPSC), will assess knowledge gaps and the effectiveness of a supplementary video-guided, print and technology-based education intervention for English- and Spanish-speaking patients in CKD Stages 3, 4, and 5 to increase LDKT knowledge and decision-making. To date, no published LDKT educational interventions have studied such a large and diverse CKD population. Methods In this RCT, 1200 English and Spanish-speaking CKD Stage 3–5 patients will be randomly assigned to one of two education conditions: ET@Home or KPSC standard of care education. Randomization will be stratified by CKD stage and primary language spoken. Those in the ET@Home condition will receive brochures, postcards, DVDs, and text messages delivering educational content in modules over a six-month period. Baseline data collection will measure demographics, transplant derailers, and the amount of previous CKD and transplant education they have received. Changes in CKD and transplant knowledge, ability to make an informed decision about transplant, and self-efficacy to pursue LDKT will be captured with surveys administered at baseline and at six months. Discussion At the conclusion of the study, investigators will understand key knowledge gaps for patients along the CKD continuum and between patients who speak different languages and have assessed the effectiveness of both English- and Spanish-language supplementary education in increasing KPSC patients’ knowledge about the opportunities for and risks and benefits of LDKT. We hope this program will reduce disparities in access to transplant. Trial Registration ClinicalTrials.gov Identifier: NCT03389932; date registered: 12/26/2017

A randomized controlled trial of Explore Transplant at Home to improve transplant knowledge and decision-making for CKD 3-5 patients at Kaiser Permanente Southern California.

BACKGROUND:Five-year survival on dialysis is only 40%, compared to 74% with a deceased donor kidney transplant (DDKT) and 87% with a living donor kidney transplant (LDKT). An American Society of Transplantation (AST) Consensus Conference recommended that patients with chronic kidney disease (CKD) Stages 3-5 have the opportunity to learn about and decide which treatment option is right for them, particularly about LDKT. However, early education about LDKT and DDKT outside of transplant centers is inconsistent and often poor, with patients in CKD 3 and 4 and ethnic/racial minorities even less likely to receive it. A new randomized control trial (RCT), in partnership with Kaiser Permanente Southern California (KPSC), will assess knowledge gaps and the effectiveness of a supplementary video-guided, print and technology-based education intervention for English- and Spanish-speaking patients in CKD Stages 3, 4, and 5 to increase LDKT knowledge and decision-making. To date, no published LDKT educational interventions have studied such a large and diverse CKD population. METHODS:In this RCT, 1200 English and Spanish-speaking CKD Stage 3-5 patients will be randomly assigned to one of two education conditions: ET@Home or KPSC standard of care education. Randomization will be stratified by CKD stage and primary language spoken. Those in the ET@Home condition will receive brochures, postcards, DVDs, and text messages delivering educational content in modules over a six-month period. Baseline data collection will measure demographics, transplant derailers, and the amount of previous CKD and transplant education they have received. Changes in CKD and transplant knowledge, ability to make an informed decision about transplant, and self-efficacy to pursue LDKT will be captured with surveys administered at baseline and at six months. DISCUSSION:At the conclusion of the study, investigators will understand key knowledge gaps for patients along the CKD continuum and between patients who speak different languages and have assessed the effectiveness of both English- and Spanish-language supplementary education in increasing KPSC patients' knowledge about the opportunities for and risks and benefits of LDKT. We hope this program will reduce disparities in access to transplant. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT03389932; date registered: 12/26/2017

Disparities in early mortality among chronic kidney disease patients who transition to peritoneal dialysis and hemodialysis with and without catheters

PURPOSE:The early period after chronic kidney disease (CKD) patients transition to end-stage renal disease (ESRD) represents the highest mortality risk but is variable among different patient populations and clinical circumstances. We compared early mortality outcomes among a diverse CKD population that transitioned to ESRD. METHODS:A retrospective cohort study (1/1/2002 through 12/31/2013) of CKD patients (age ≥ 18 years) who transitioned to peritoneal dialysis (PD), hemodialysis (HD) with arteriovenous fistula/grafts, and HD with catheters was performed. Multivariable Cox regression modeling was used to estimate 6-month all-cause mortality hazard ratios (HR) among the three treatment groups after adjustment for patient and clinical characteristics. RESULTS:Among 5373 ESRD patients (62.7 years, 41.3% females, 37.5% Hispanics, 13.3% PD, 34.9% HD with fistula/graft, 51.8% HD with catheter), 551 (10.3%) died at 6 months. Mortality rates were highest immediately after transition (299 deaths per 1000 person-years in first month). Compared to PD patients, the 6-month mortality HR (95% CI) was 1.87 (1.06-3.30) in HD with fistula/graft patients and 3.77 (2.17-6.57) in HD with catheter patients. Inpatient transition (HR 1.32), acute kidney injury (HR 2.06), and an eGFR ≥ 15 vs 5-9 (HR 1.68) at transition were also associated with higher early mortality risk. CONCLUSION:Among a diverse CKD population who transitioned to ESRD, we observed considerable differences in early mortality risk among PD, HD with fistula/graft, and HD with catheter patients. The identification of patient-specific and clinical environmental factors related to high early mortality may provide insights for managing advanced stages of CKD and shared decision making